Tag Archives: Action Against Medical Accidents

Annual Reviews of Avoidable Harm in Hospitals / Weekly NHS Reviews (BBC News / Department of Health)

Posted on February 10, 2015 by Dementia and Elderly Care News

Summary Health Secretary Jeremy Hunt has announced a programme of annual reviews into avoidable deaths in English hospitals. The plan is to improve patient safety and promote the culture of openness and honesty in the NHS. Full Text Link Reference … Continue reading →

Posted in Acute Hospitals, BBC News, Department of Health, For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), In the News, Integrated Care, Management of Condition, National, NHS, Person-Centred Care, Quick Insights, Standards, Statistics, UK, Universal Interest | Tagged Accountability in Health and Social Care, Action Against Medical Accidents, Acute Care, Acute Hospital Care, Acute Hospitals, Alignment of Services Across Health and Social Care Sectors, Annual Reviews of Avoidable Harm in Hospitals, Avoidable Harm, Avoidable Hospital Mortality, Avoidable Mortality, Basildon and Thurrock University Hospitals NHS Foundation Trust, Bernard Jenkin: Chair of House of Commons Public Administration Select Committee, Buckinghamshire Healthcare NHS Trust, Buddying, Buddying Schemes, Burton Hospitals NHS Foundation Trust, Care in General Hospitals, Chief Medical Examiners, Clinical Incidents in the NHS, Colchester Hospital University NHS Foundation Trust, Commons Public Administration Select Committee (PASC), County Hospital Louth, Dame Julie Mellor: Parliamentary and Health Ombudsman Service, Deaths Associated with Hospitalisation, Delayed Discharges, Dr Foster, Dr Foster Intelligence, Dr Katherine Rake OBE, East Lancashire Hospitals NHS Trust, Eric Pickles: Communities Secretary, Former Health Secretary Jeremy Hunt, General Hospital Care, General Hospitals, General Medical Wards, George Eliot Hospital NHS Trust, Governance, Governance and Accountability, Grantham and District Hospital, Health and Social Care, Health and Social Care Integration, Health and Social Care Leaders, Hospital Standardised Mortality Ratios (HSMRs), House of Commons Public Administration Select Committee, House of Commons Public Administration Select Committee (PASC), Imperial College (Dr Foster Unit), Integration of Health and Social Care, Investigative Capacity for NHS Patient Safety, Joined-Up Care, Keogh Mortality Review, Keogh Review, Lincoln County Hospital, Medical Accidents, Medical Accidents: Investigation, Medway NHS Foundation Trust, Never Events, Never Events Data, NHS England's Sign Up to Safety Campaign, NHS Medical Accidents Investigation Unit (Proposal), NHS Trusts and Foundation Trusts in Special Measures: 18 Months On, North Cumbria University Hospitals NHS Trust, Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, Northern Lincolnshire and Goole NHS Foundation Trust, Oliver Letwin: Cabinet Office Minister, Openness and Transparency, Openness. Transparency, Parliamentary and Health Service Ombudsman (PHSO), Patient and Public Participation, Patient Care, Patient Safety, Patient Satisfaction, Patient-Safety-Related Hospital Deaths in England, Pilgrim Hospital Boston, Preventable Hospital Deaths, Preventable Hospital Mortality, Proactive Weekly NHS Performance Reviews, Professor Nick Black, Providers, Public Administration Select Committee (PASC), Quality Improvement, Quality of Care, Rt Hon Jeremy Hunt MP: Former Secretary of State for Health, Sherwood Forest Hospitals NHS Foundation Trust, Sign up to Safety, Sign Up to Safety Campaign, Simon Stevens: Chief Executive of NHS England, Sir Jeremy Heywood, Summary Hospital-level Mortality indicator (SHMI), Surgical Never Events, Tameside NHS Foundation Trust, Transitions Between Health and Social Care, Transparency and Accountability, Troubleshooting Reviews of NHS Performance, United Lincolnshire Hospitals NHS Trust, Weekly Ministerial-Level Troubleshooting Reviews of NHS Performance, Weekly NHS Reviews: De-Weaponising the NHS | Leave a comment

Berwick Report One Year On: NHS England’s Progress on Patient Safety (NHS England / Health Foundation)

Posted on August 21, 2014 by Dementia and Elderly Care News

Summary It is just over one year since Professor Don Berwick published the “A promise to learn: a commitment to act” report on the safety of patients in England in the wake of the Francis Inquiry. This is a brief review of progress since … Continue reading →

Posted in Acute Hospitals, Commissioning, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), Health Foundation, Local Interest, Management of Condition, National, NHS, NHS England, Patient Care Pathway, Person-Centred Care, Quick Insights, Standards, UK, Universal Interest | Tagged Academic Health Science Networks (AHSNs), Action Against Medical Accidents, Airline Industry (Zero Harm), BBC Health News, Berwick Review of Patient Safety, Collaborative Leadership, Collaborative Projects, Collaborative Working, Continuous Learning, Continuous Learning Culture, Culture Change, Culture of Zero-Harm, Dr Mike Durkin: NHS England’s Director of Patient Safety, Ethic of Learning, Fitness to Practise, Fitness to Practise Policy Team: General Medical Council, Francis Inquiry Report, General Medical Council (GMC), GMC Sanctions Guidance, GMC Sanctions: Consultation, Good Medical Practice, Harm Free Care, High Quality Care, Hospital Mortality Rates, Hospital-Acquired Infections, IHI: Institute for Healthcare Improvement, Improvement Collaboratives in Health Care, Incident Reports, Incorrect Priorities, Information Centre for Health and Social Care, Institute for Healthcare Improvement (IHI), Institute of Healthcare Improvement (IHI) Trigger Tool, Kaizen, Leadership, Learning From Mistakes, Local Patient Safety Collaboratives, Local Patient Safety Collaboratives Programme, Measures of Harm, Measuring Safety Culture, Medical Practitioners Tribunal Service (MPTS), Mid Staffordshire NHS Foundation Trust, Mortality Rates, MPTS Panels, National Patient Safety Alerting System (NPSAS), Never Events, Never Events Data, NHS Culture, NHS England National Patient Safety Alerting System, NHS Improving Quality (NHS IQ), NHS Improving Quality (NHSIQ), NHS Regulation, NHS Safety Thermometer, NHS Safety Thermometer Patient Data, No Harm Culture, Open Culture, Openness, Openness and Transparency, PANICOA (Prevention of Abuse and Neglect in the Institutional Care of Older Adults), Patient Harms, Patient Safety, Patient Safety Collaboratives, Patient Safety Collaboratives Programme, Patient Safety Indicators, Patient Safety Strategies, Professor Don Berwick, Quality Control, Quality Improvement, Quality Improvement Approaches, Quality of Care, Quality Patient Care, Regulation, Repercussions From the Francis Inquiry Report, Responses to the Francis Inquiry Report, Sign Up to Safety Campaign, Sign Up to Safety Pledges, Target-Chasing (Hitting the Target Missing the Point), Training and Capacity-Building, Transparent Learning Culture, Zero Harm, Zero Tolerance Healthcare | Leave a comment

Practical and Measurable Patient Safety Improvement Plans (BBC News)

Posted on March 26, 2014 by Dementia and Elderly Care News

Summary Health Secretary Jeremy Hunt wants NHS trusts to develop plans for halving, by 2016-17, “avoidable harm” to patients arising from preventable problems such as medication errors, blood clots and bedsores. It is estimated that this could eliminate a third of … Continue reading →

Posted in Acute Hospitals, BBC News, Department of Health, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Social Workers (mostly), In the News, National, NHS, NHS Digital (Previously NHS Choices), Patient Care Pathway, Quick Insights, Standards, UK, Universal Interest | Tagged Action Against Medical Accidents, Action against Medical Accidents (AvMA), Active Engagement, Acute Care, Acute Hospital Care, Acute Hospitals, Aligning Forces for Quality, American Hospital Association – Health Research & Educational Trust (AHA-HRET) Survey of Hospitals on Patient Engagement Strategies, Armstrong Institute for Patient Safety and Quality at Johns Hopkins, Avoidable Harm, Avoidable Mortality, Avoidance of Litigation, Barriers to Engagement, Bed Sores, Candour, Candour: Safety and Improvement, Care of Older Adults in Acute NHS Trusts, Consumer Engagement in Patient Safety, Contractual Duty of Candour, Covering-Up Mistakes, Declaration on Engagement for Global Health, Engagement on Quality, Former Health Secretary Jeremy Hunt, General Hospital Care, General Hospitals, Gordon and Betty Moore Foundation, Hospital Aquired VTE, How Safe Is My Hospital (NHS Choices), Hydration, Improving Patient Safety, Incentivising Candour, Incident Reporting, Learning From Mistakes, Learning Organisations, Litigation Claims, Local Change Agents, Lower-Than-Expected Incident Reporting (Problematic), Measures of Harm, Measuring Harm Free Care, Medication Errors, Misdiagnosis, MITSS (Medically Induced Trauma Support Services), National Committee for Quality Assurance (NCQA), National Patient Safety Foundation’s Lucian Leape Institute, National Report and Learning System, NHS Litigation Authority, NHS Litigation Authority (NHS LA), NHS Patient Safety Culture, NHS: Safest Healthcare System in the World (Ambition), NPSF: National Patient Safety Foundation, Open and Honest Incident Reporting, Openness and Transparency, Participation in Diagnosis, Partnering with Patients and Families, Patient and Family Engagement, Patient Engagement, Patient Engagement Strategies, Patient Experience, Patient Safety, Patient Safety Champions, Patient Safety Improvement, Patient Safety Indicators, Patient Safety Strategies, Potentially Preventable Complications in Hospitalis, PPE: Patient and Public Engagement, Pressure Ulcers, Pressure Ulcers: Prevention, Pressure Ulcers: Risk Assessment, Preventable Deaths in English Acute Hospitals, Preventable Hospital Deaths, Preventable Hospital Mortality, Preventable Mortality, Putting Patients First, Reducing Litigation Costs, Reporting Culture, Reporting of Incidents, Roundtable on Consumer Engagement, Rt Hon Jeremy Hunt MP: Former Secretary of State for Health, SAFE: Safety Action for England, Safety Action for England (Safe) Team, Safety Is Personal, Safety Metrics, SDM: Shared Decision Making, Serious Mistakes, Severe Harm, Sign up to Safety, Statutory Duty of Candour, Surveillance and Reporting, Threshold for Duty of Candour, Transparency, Transparency and Accountability, Unconscious Incompetence, Unsafe Care, User Experience, Venous Thromboembolisms (VTEs), Virginia Mason Hospital: Seattle, VTE (Venous Thromboembolism), VTE Risk Assessment, World Innovation Summit for Health (WISH), Zero Harm | Leave a comment

Statutory Duty of Candour Moves Closer (BBC News / Royal College of Surgeons)

Posted on March 8, 2014 by Dementia and Elderly Care News

Summary The review commissioned by the Government in the wake of the Francis Inquiry report has recommended that the NHS must be open and honest about mistakes. The report calls for a statutory duty of candour in the case of … Continue reading →

Posted in BBC News, Department of Health, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Social Workers (mostly), In the News, National, NHS, Patient Care Pathway, Quick Insights, RCN, Standards, UK, Universal Interest | Tagged Action Against Medical Accidents, Audit Loop, Australian Commission of Safety and Quality in Health Care, Australian Open Disclosure Framework, Avoidable Harm, BBC Health News, Berwick Review of Patient Safety, Breach of Acceptable Practice, Bureaucracy, Candid Conversations: Treating Patients as Equals, Candour, Candour: Safety and Improvement, Care Quality Commission (CQC), Communicating With Patients About Medical Errors, Compassionate Care, Consequences of the Francis Inquiry Report, Culture Change, Culture of Candour, Culture of Zero-Harm, Excessive Regulatory Responses, Fear of Litigation, Fear of Professional Regulatory Consequences, Foundation Trust Network (FTN), Francis Inquiry, Harm, Harm Free Care, Improving Patient Safety, Incentivising Candour, Incident Disclosure, Incidents Errors and Near Misses, Learning From Mistakes, Mid Staffordshire NHS Foundation Trust, Misplaced Paternalism, Moderate Harm, National Reporting and Learning System (NRLS), NHS Culture, NHS Litigation Authority, NHS Litigation Authority (NHS LA), No Harm Culture, Open Culture, Openness, Openness and Transparency, Organisational Reputation, Patient Safety, Patient Safety Incidents, Post-Paternalist Age, Pressure Ulcers, Professional Standards Authority, Professor Norman Williams, Professor Norman Williams: President of Royal College of Surgeons, Prolonged Psychological Harm, Reduction in Bureaucracy, Repercussions From the Francis Inquiry Report, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Reporting Culture, Risk and Consent, Royal College of Nursing (RCN), Royal College of Surgeons, Royal College of Surgeons of England (RCSENG), Sir David Dalton: Salford Royal Hospital, Stafford Hospital, Statutory Duty of Candour, Threshold for Duty of Candour, Transparency, Transparency and Accountability, Violation, Wilful Neglect | 1 Comment

Doctors and Nurses: Sanctions for Neglect? (BBC News)

Posted on November 16, 2013 by Dementia and Elderly Care News

Summary The government is said to be proposing changes to the law, whereby doctors and nurses found guilty of “wilful neglect” of their patients could face up to 5 years in jail. Read more: BBC News. Doctors and nurses may face jail for neglect. … Continue reading →

Posted in Acute Hospitals, BBC News, Community Care, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Social Workers (mostly), In the News, Management of Condition, National, NHS, Quick Insights, Standards, UK, Universal Interest | Tagged Abuse, Abuse of Vulnerable Adults, Action Against Medical Accidents, Action against Medical Accidents (AvMA), Adult Safeguarding, BBC Health News, Berwick Review of Patient Safety, Candour, Defensive Leadership, Fear is Toxic, Fear of Raising Concerns About Care, Neglect, Openness, Openness and Transparency, Professor Don Berwick, Repercussions From the Francis Inquiry Report, Safeguarding, Statutory Duty of Candour, Transparency and Accountability, Trust Blame and the Culture of Defensiveness, Whistleblowing, Wilful Neglect, Willful Blindness | Leave a comment

NHS Complaints Review Report (BBC News)

Posted on October 28, 2013 by Dementia and Elderly Care News

Summary The government-backed review investigating how the NHS in England handles complaints has been published. An achievement of this review is to have persuaded twelve important organisations to sign-up to a series of pledges. Recommendations include improving quality of care, improving how … Continue reading →

Posted in Acute Hospitals, BBC News, CQC: Care Quality Commission, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), Health Education England (HEE), In the News, National, NHS, NHS England, Patient Care Pathway, Person-Centred Care, Quick Insights, Standards, UK, Universal Interest | Tagged Action Against Medical Accidents, Acute Care, Acute Hospitals, BBC Health News, Candour, Care of Older Adults in Acute NHS Trusts, Comments and Complaints, Complaint and Redress, Complaint Handling, Complaints, Dementia Care in Acute Settings, Formal Complaints, Formal Complaints Process, Francis Inquiry Report, Hospital Complaints, Mid Staffordshire NHS Foundation Trust Inquiry, NHS Complaints Process, NHS Complaints System: Department of Health Review, NHS Constitution and Whistleblowing, NHS Hospital Complaints, NHS Hospital Complaints System, Nursing and Midwifery Council (NMC), Openness, Openness and Transparency, Patient Complaints, Principles of Good Complaint Handling, Reactions to the Francis Inquiry Report, Report of Mid Staffordshire NHS Foundation Trust Public Inquiry, Responses to the Francis Inquiry Report, Review of NHS Complaints System, Statutory Duty of Candour, Transparency, Transparency and Accountability, User Complaints, Whistleblowing | Leave a comment

Proposals for Zero Harm Culture in NHS (BBC News / Department of Health)

Posted on August 6, 2013 by Dementia and Elderly Care News

Summary Professor Don Berwick of the Institute for Healthcare Improvement (IHI), which he co-founded in Cambridge (Massachusetts), is expected to release plans to create a “zero harm” culture in the NHS in England today. Prof. Berwick, being a world expert on patient safety, was asked by ministers … Continue reading →

Posted in Acute Hospitals, BBC News, Community Care, Falls, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Social Workers (mostly), In the News, Integrated Care, Management of Condition, Models of Dementia Care, National, NHS, Nutrition, Patient Care Pathway, Physiotherapy, Practical Advice, Proposed for Next Newsletter, Quick Insights, Standards, Statistics, UK, Universal Interest | Tagged Abuse, Abuse of Vulnerable Adults, Action Against Medical Accidents, Action against Medical Accidents (AvMA), Airline Industry (Zero Harm), BBC Health News, Berwick Review of Patient Safety, Best Practice, Catheters and UTIs, Culpability, Culture Change, Culture of Zero-Harm, DVT, Elder Abuse, Empowerment, Enforcement, Engagement, Ethic of Learning, Experimental Statistics, Falls, Fear is Toxic, Francis Inquiry Report, Harm Free Care, High Quality Care, Hospital Mortality Rates, Hospital-Acquired Infections, IHI: Institute for Healthcare Improvement, Imperial College Centre for Patient Safety and Service Quality, Incident Reports, Incorrect Priorities, Information Centre for Health and Social Care, Institute for Healthcare Improvement (IHI), Institute of Healthcare Improvement (IHI) Trigger Tool, Leadership, Learning From Mistakes, Liability, Measures of Harm, Measuring Safety Culture, Mid Staffordshire NHS Foundation Trust, Mortality Rates, National Advisory Group on the Safety of Patients in England, Neglect, NHS Culture, NHS Regulation, NHS Safety Thermometer, NHS Safety Thermometer Patient Data, No Harm Culture, Old Pressure Ulcers, Open Culture, Openness, Openness and Transparency, PANICOA (Prevention of Abuse and Neglect in the Institutional Care of Older Adults), Patient and Public Involvement (PPI), Patient Harms, Patient Safety, Patient Safety Indicators, Patient Safety Strategies, Patient Voice, Patients First and Foremost, Pre-Surgery Checklists, Pressure Ulcer Incidence, Pressure Ulcer Prevalence, Pressure Ulcers, Professor Don Berwick, Quality Control, Quality Improvement, Quality of Care, Quality Patient Care, Regulation, Repercussions From the Francis Inquiry Report, Responses to the Francis Inquiry Report, Review of Central Returns Steering Committee (ROCR), ROCR Approval, ROCR: Review of Central Returns, Safe Staffing, Safe Staffing for Older People in Hospitals, Shaping Culture, Staffing, Staffing (Hospitals), Staffing Levels, Target-Chasing (Hitting the Target Missing the Point), Training and Capacity-Building, Transparent Learning Culture, Urinary Catheterisation, Urinary Tract Infections, Urinary Tract Infections (in Patients with Catheters), Urinary Tract Infections (UTIs), Venous Thromboembolisms (VTEs), VTE (Venous Thromboembolism), VTE Prophylaxis, VTE Risk Assessment, Zero Harm, Zero Tolerance Healthcare | Leave a comment

NHS Failings Suppressed for “Political” Reasons? (BBC News / Department of Health)

Posted on July 15, 2013 by Dementia and Elderly Care News

Summary A report (NHS England‘s Keogh review), ordered by the government after the publication of the Francis Inquiry into Stafford Hospital, indicates that 14 NHS trusts – with higher-than-expected mortality rates over recent years – may have contributed to 13,000 excess deaths compared with the national average in 2005-10. Professor Sir … Continue reading →

Francis Inquiry Report: Full Report (Mid Staffordshire NHS Foundation Trust Inquiry)

Posted on February 9, 2013 by Dementia and Elderly Care News

Summary High mortality rates and poor standards of care provided at the Mid Staffordshire NHS Foundation Trust resulted in concern about services and management in the Trust. This three-volume Francis Inquiry report investigates the causes and lessons learned. “…[the widespread] disconnect between … Continue reading →

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