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Found 465 results
  1. Content Article
    The National Guardian’s Office (NGO) leads, trains and supports a network of Freedom to Speak Up (FTSU) Guardians in England. It also conducts speaking up reviews to identify learning and support improvement of the speaking up culture of the healthcare sector. This is their updated strategy to support cultural change in healthcare to improve worker experience and patient safety.
  2. Content Article
    The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration it can be difficult for them to effectively contribute to escalation of care. This article looks at a process evaluation of the RESPOND quality improvement programme—Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration. It identifies enablers and barriers to the implementation of patient-led escalation systems found during the programme.
  3. Content Article
    Listening to the voices of workers is essential for a safe and effective healthcare for workers, patients and the public. Freedom to Speak Up Guardians provide an opportunity for organisations to learn from these voices which may not otherwise be heard. Freedom to Speak Up Guardians are required to report non-identifiable information on the cases they receive both locally to their boards and senior leadership and to the National Guardian’s Office. This report summarises the data shared by Guardians about the speaking up cases they received between 1 April 2023 and 31 March 2024.
  4. Content Article
    Research on clinical deterioration has mostly focused on clinicians' roles. Although patients and families can identify subtle cues of early deterioration, little research has focused on their experience of recognising, speaking up and communicating with clinicians during this period of instability. This study explored patient and family narratives about their recognition and response to clinical deterioration and their interactions with clinicians prior to and during Medical Emergency Team (MET) activations in hospital.
  5. News Article
    A “dysfunctional” culture at the UK nursing regulator is threatening public safety, according to a damning report that found the Nursing and Midwifery Council (NMC) took seven years to strike off a nurse who had been accused of rape and sexual assault. Staff at the regulator broke down in tears “as they recounted their frustrations over safeguarding decisions that put the public at risk”, according to the authors of an independent review of the regulator. The review team highlighted a “toxic culture” at the NMC, with one former employee describing their section of the organisation as a “hotbed of bullying, racism and toxic behaviour”. The report also shone a spotlight on suicides by nurses caught up in long drawn-out fitness to practise investigations, highlighting how some nurses had been under investigation for nearly 10 years. The authors commented on the NMC’s backlog of 6,000 cases, which meant some nurses were forced to wait four or five years for their investigation to be completed, even though some cases were “baseless complaints where no further action is required”. Read more Source: The Guardian, 9 July 2024
  6. Content Article
    An independent review of the Nursing and Midwifery Council (NMC)'s culture has highlighted safeguarding concerns, and found that people working in the organisation have experienced racism, discrimination and bullying. We take this extremely seriously and will deliver a culture change programme rooted in the review’s recommendations. The NMC commissioned Nazir Afzal OBE and Rise Associates to carry out the review after concerns were raised about the organisation’s culture, including racism and fear of speaking up. Over 1,000 current and former NMC colleagues, plus more than 200 panel members who sit on fitness to practise hearings, shared their lived experiences as part of the review. The NMC accepts the report’s recommendations.
  7. News Article
    A prestigious teaching hospital constructively dismissed the head of its transplant unit after he raised safety concerns about Great Ormond Street Hospital, a tribunal heard. An employment judge ruled Professor Nizam Mamode had been constructively dismissed by Guy’s and St Thomas’ Foundation Trust, who employed him as their clinical lead for adult and peadiatric transplants. GSTT suspended Professor Mamode from practising in June 2020 and removed him from his leadership role, saying his behaviour had caused relationships with colleagues to break down. Professor Mamode told the tribunal these complaints had been made after “collusion” with GOSH after he had raised safety concerns with that trust’s medical director Sanjiv Sharma. He claimed another consultant at GOSH, where Professor Mamode held an honorary post, had put a patient at risk. These concerns prompted a review of the renal transplant service between January and March 2020. HSJ asked GOSH for the result of this review and the trust said “no immediate safety concerns were found”. Read full story (paywalled) Source: HSJ, 8 July 2024
  8. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Making Families Count is an organisation that offers practical training based on lived experience to healthcare professionals.  Rosi talks to us about how MFC training benefits patient safety and improves the way in which patients and families are involved in incident investigations. She explains how she came to be involved in MFC after the death of her son Nico and outlines the vital importance of seeing patient and family voices as equal to those of people working for healthcare organisations.
  9. Content Article
    Read the latest case studies from the National Guardian’s Office.
  10. Content Article
    In the dynamic landscape of healthcare, the unexpected deterioration of a hospital patient presents formidable challenges for medical professionals and families alike. It is during these critical moments that the concept of patient rescue becomes profoundly significant. Families, empowered with knowledge and effective communication strategies, play a pivotal role alongside healthcare providers in advocating for their loved ones and contributing to the success of rescue efforts. Watch this video from the World Patients Alliance to enhance your skills and confidence in advocating for patients' needs.
  11. Content Article
    A frank account from a healthcare assistant on the bullying she experienced after raising concerns at the care home she worked in.
  12. News Article
    Healthcare staff who deliberately withhold information should face criminal prosecution in cases involving patient safety and deaths, according to Northern Ireland's human rights commissioner. In her first public interview on duty of candour, Alyson Kilpatrick told BBC News NI there was an obligation on doctors to be fully truthful in order to protect lives. A duty of candour is an onus on staff to be open and transparent with patients and families when mistakes are made in a patient's care. However, the British Medical Association (BMA) does not agree that criminal sanctions should be linked with a duty of candour, and has said it would go against creating a culture of openness and transparency. Alan Roberts, whose daughter's death was examined by the Northern Ireland hyponatraemia inquiry which found there had been a "cover-up" into how she died, said doctors must be legally bound to tell the truth. Claire Roberts was one of five children whose deaths at hospitals in Northern Ireland were examined by the 14-year-long inquiry. It was heavily critical of a health service it deemed to be "self-regulating and unmonitored". Mr Roberts said "the public will be shocked to find there is no legal binding duty on a doctor to tell a patient when there have been failures or when they've been at fault". Read full story Source: BBC News, 25 June 2024
  13. News Article
    A rising proportion of doctors will not blow the whistle over patient safety concerns for fear of retribution, leading medics said. The British Medical Association (BMA) surveyed doctors from around the UK in 2018 and again in 2024. A rising proportion said they would not feel confident raising concerns about patient care – 26% of 1,578 doctors in 2024 compared with 10% of around 7,900 doctors surveyed in 2018. Three in five (61%) of those polled in 2024 said they may not raise concerns because they were “afraid” they or colleagues could be “unfairly blamed or suffer adverse consequences”. Meanwhile 45% said they feel that their managers discourage them from raising concerns – up from 20% cent in 2018. The BMA said that doctors are now “more frightened than ever” to speak up when they see patient safety issues, or levels of care at risk. Professor Philip Banfield, chairman of council at the BMA, is set to highlight a culture of “protectionism rather than accountability”. Read full story Source: The Independent, 23 June 2024
  14. Content Article
    In healthcare, 'speaking up' refers to when healthcare workers raise concerns regarding patient safety through questions, sharing information, or expressing their opinion to prevent harmful incidents and ensure patient safety. Conversely, withholding voice is an act of not raising concerns, which could be beneficial in certain situations. Factors associated with speaking up and withholding voices are not fully understood, especially in strong authoritarian societies, such as Malaysia. This study aimed to examine the factors associated with speaking up and withholding the voices of healthcare workers in Malaysia, thus providing suggestions that can be used in other countries facing similar patient safety challenges.
  15. News Article
    The mother of a 13-year-old girl who died of sepsis has said she hopes Martha’s rule, which gives patients and their families the right to a second medical opinion, will “upend” the “hierarchy” on hospital wards. Merope Mills, who campaigned with her husband, Paul Laity, to give families more say regarding care following the death of their daughter Martha, also called for a “mutual respect” between patients and doctors. More than 140 NHS sites in England have agreed to implement Martha’s rule, a patient safety initiative that will give patients and their families round-the-clock access to a rapid review by an independent critical care team from elsewhere in the hospital if they feel their health, or that of a family member, is deteriorating and they are not being listened to. Speaking at NHS ConfedExpo on Wednesday, Mills, an executive editor at the Guardian, said: “My big thing is, I think we need to be more equal. “It’s a very unequal place, a hospital ward, and there’s hierarchy and it’s very steep and it’s very strict. And, you know, when I first started talking about that, I sort of thought the nurses were at the bottom of the hierarchy. “And I refer to that because they didn’t feel that ability to speak up in Martha’s case. But I’ve actually come to realise that the people at the bottom of the hierarchy are the patients. “They are the ones with the least power and I just would like to upend that and just have a sense of mutual respect between doctor and patient.” Read full story Source: The Guardian, 14 June 2024
  16. Content Article
    Published on Steve Turner's blog site, this article gives a summary of the The Protection for Whistleblowing Bill & the Office of the Whistleblower, and answers some frequently asked questions.
  17. Content Article
    In 1990, 10-year-old Robbie Powell died due to undiagnosed Addison’s disease. Tragically, his death was preventable. Concerns that Robbie may have had Addison’s disease had been raised following a previous hospital admission and a diagnostic test requested, but this was not followed up or shared with his parents, Will and Diane. In the two weeks before Robbie died, Robbie was seen by five GPs on seven occasions, but his parents were consistently told that there was nothing seriously wrong with their son. Robbie’s father Will has worked for decades to uncover why his son died and how the doctors and organisations involved responded following Robbie’s death. In this long-read interview, Will describes the events that led to Robbie’s death and his subsequent fight for justice, including his role in the successful campaign which resulted in organisational legal duty of candour. He talks about the devastating impact that having the truth withheld continues to have on his family and other families. Will then outlines what needs to be done to better protect families and ensure they get the full truth when a child dies due to avoidable harm. Please note: readers may find the following content distressing.
  18. Content Article
    In this paper, published by Healthcare, authors proceed in two steps. First, they expand the existing base of literature on the interpersonal aspect of a safety climate by presenting a conceptual model of psychological safety and joint problem-solving orientation and proposing how, individually and together, they promote safety improvement and worker retention in healthcare. Second, they conduct an exploratory test of these relationships using empirical data from a large healthcare organization in the US.
  19. Content Article
    Medtech companies are continually developing new medical devices and products for use in healthcare, and ensuring that each one is safe to use should be the top priority of every company. In this anonymous blog, a nurse shares their experience of being employed by a start-up producing a new piece of equipment for use in cardiac surgery. They soon discovered their values did not match up, as the company prioritised getting their new product to market above patient safety. The writer talks about the personal cost of repeatedly speaking up for safety and describes the importance of working for an employer that sees patient safety as the top priority and recognises that it goes hand in hand with commercial success.
  20. Content Article
    NHS bosses are destroying the careers of whistleblowers who stand up to protect patients’ lives, according to an exclusive investigation by The Telegraph. More than 50 doctors and nurses told us they have been targeted after raising concerns about upwards of 170 patient deaths and nearly 700 cases of poor care. In this episode of The Daily T podcast, Kamal Ahmed and Camilla Tominey are joined by the journalists behind the story, Janet Eastham and Gordon Rayner. This discussion takes in the video from 2 minutes 52 seconds to 16 minutes 40 seconds.
  21. Content Article
    In this interview, Patrick Christys from GB News speaks to former Consultant Urological Surgeon, Peter Duffy, about the treatment of whistleblowers in the NHS who raise patient safety concerns. You can find out more about Peter’s experiences in his books Whistle in the Wind and Smoke and Mirrors. To watch the interview, click on the link below.
  22. Event
    This conference brings together leading experts at the forefront of Martha’s Rule implementation and offers a comprehensive and practical guide for clinical staff to seamlessly integrate Martha’s Rule into their daily practice. The conference delves into the caregiver’s perspective, principles and implications of Martha’s Rule, legal and patient safety considerations, effective communication strategies, and the use of technology in the adoption of Martha’s Rule. Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/marthas-rule-patient-safety or email aman@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for the discount code. Follow on X @HCUK_Clare #MarthasRule
  23. Content Article
    Despite growing awareness of diagnostic error, most healthcare systems do not track or record diagnostic quality, and many diagnostic safety events are not recognised. Without methods to identify, measure, investigate and analyse events, healthcare organisations cannot understand causes of diagnostic errors, identify contributing factors or create solutions. One of the best ways to collect information about diagnostic errors is through self-reporting by patients and healthcare professionals. This issue brief from the Agency for Healthcare Research and Quality looks at how to foster psychological safety and organisational safety culture in order to reduce harm from diagnostic error. 
  24. News Article
    More than 50 NHS whistleblowers claim to have lost their jobs—with some driven to the brink of suicide—after standing up to protect patients’ lives as bosses bury their concerns. The group of doctors and nurses said that they had been targeted after raising concerns about more than 170 patient deaths and nearly 700 cases of poor care. One consultant said that it was the “biggest scandal within our country” and claimed the true number of avoidable deaths was “astronomical”. Instead of addressing the problems, the whistleblowers claim that NHS bosses are spending millions of pounds of taxpayers’ money on hiring law firms and private investigators to investigate them instead. Last year Rob Behrens, the health ombudsman, warned The Times Health Commission that patient safety was at risk due to “toxic” and hierarchical behaviour among NHS doctors. Professor Phil Banfield, the chairman of the council of the British Medical Association, which represents doctors, wrote in The Daily Telegraph that whistleblowing “is not welcomed by NHS management… NHS trusts and senior managers are more concerned with protecting personal and organisational reputations than they are with protecting patients.” In one case, the NHS spent more than £4 million on legal action against a single whistleblower, which included £3.2 million in compensation. Among the clinicians interviewed, 40 said that their employer took “no positive action” to address patient safety concerns; 36 said that patients remained at risk at their place of work; 19 said that NHS trusts covered up the problems, and ten said that their employers had denied there was a problem. Whistleblowers’ representatives are urging the government to require independent medical assessments for claims and to ban the suspension or exclusion of doctors for speaking out about patient safety. Dr Naru Narayanan, president of the hospital doctors’ union, has called for an independent national whistleblowing body outside of the NHS to register protected disclosures and protect individuals against recriminations. The Times Health Commission recommended that a no-blame compensation scheme should be introduced for medical errors, with settlements determined according to need. Backed by Jeremy Hunt, the chancellor, the scheme would help end the deadly cycle of NHS scandals and cover-ups and ensure families receive timely support. Read full story (paywalled) Source: The Times, 15 May 2024
  25. Content Article
    Project PIVOT is a new initiative led by Patients for Patient Safety US (PFPS US) that aims to advance the implementation of patient-centred patient-reported experiences (PREs) and patient-reported outcomes (PROs) to improve patient safety, diagnostic accuracy and equity in healthcare. Project PIVOT will provide an opportunity for diverse patients, communities of patients and patient organisations to collaborate with national and international experts and provide input via novel engagement methods to identify and prioritise PREs and PROs which are related to patient safety, diagnostic accuracy and equity–things that matter most to patients. Patients will also have opportunities to identify how and when they prefer to report their experiences and outcomes. Additionally, Project PIVOT will engage healthcare system leaders to identify and prioritise their PREs and PROs to explore possible synergies and integration with the PROs and PREs identified by patients. Project PIVOT is accepting applications from individuals interested in joining the project via the PFPS US website.
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