Tag Archives: Learning From Mistakes

Older People Reluctant to Complain About Poor Health and Care Services (BBC News / PHSO / Healthwatch)

Posted on January 2, 2016 by Dementia and Elderly Care News

Summary The Parliamentary and Health Service Ombudsman (PHSO) has noted that it receives disproportionately few complaints from older people than expected i.e. relative to elderly people’s higher usage of NHS and social care services. The PHSO’s latest report indicates that … Continue reading →

Posted in Acute Hospitals, Age UK, BBC News, Commissioning, Community Care, For Carers (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), In the News, Integrated Care, Management of Condition, National, Person-Centred Care, Quick Insights, Standards, UK, Universal Interest | Tagged Avoidable Harm, BBC Health News, Caroline Abrahams: Director of Age UK, Complainant and Non-Complainant Survey (PHSO), Complainant Survey, Complaints Handling, Culture Change, Customer Contact & Complaints, Dame Julie Mellor: Parliamentary and Health Ombudsman Service, Effective Complaints Handling, End-User Experience, Every Complaint Matters, Experiences, Fear of Raising Concerns About Care, Feeling In the Wrong When Complaining, Formal Complaints, Formal Complaints Process, Governance, Healthwatch, Healthwatch England, Independent Age, Leadership, Leadership and Culture, Learning Culture, Learning From Mistakes, LGO: Local Government Ombudsman, Local Government Ombudsman, My Expectations For Raising Concerns And Complaints (PHSO / LGO / Healthwatch England), Negative Experiences of Care, NHS Complaints Advocacy, NHS Complaints Process, NHS Constitution, NHS Culture, NHS Governance and Accountability, NHS Governance of Complaints Handling, NHS Hospital Complaints, Non-Complainants Survey, Non-Complainants Survey (Independent Age), Offered Support (To Complain), Openness and Transparency, Parliamentary and Health Service Ombudsman, Parliamentary and Health Service Ombudsman (PHSO), Patient Experience, Patients Support Networks, Principles of Good Complaint Handling, Public Services Complaints, Putting Patients First, Putting Things Right, Quality Improvement, Raising Concerns, Raising Concerns Policy, Raising Standards, Reducing Complexity, Reluctance to Raise Concerns About Care, Remedying Individual Injustice and Improving the Experience of Others, Repercussions From the Francis Inquiry Report, Service User Experience, Speaking Up: Resolving NHS Complaints and Preventing Problems Recurring, Suffering in Silence, Support Networks, Transparency, Transparency and Accountability, Transparent Learning Culture, User Complaints, User Experience, Valuing Complaints | 1 Comment

More on Patient Safety Concerns (BBC News / CQC)

Posted on October 15, 2015 by Dementia and Elderly Care News

Summary A Care Quality Commission (CQC) review reports that three-quarters of hospitals visited under its new inspection regime so far have shown some safety problems. Safety remains an issue across both the NHS and care sectors in England, there being … Continue reading →

Professional Duty of Candour: Openness and Honesty When Things Go Wrong (NMC / GMC / Nursing Times / BBC News)

Posted on July 2, 2015 by Dementia and Elderly Care News

Summary The General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) have jointly published guidance explaining the standards expected of doctors, nurses and midwives in the UK when things go wrong during healthcare. Professionals, in turn, require the … Continue reading →

Posted in Acute Hospitals, Community Care, For Doctors (mostly), For Nurses and Therapists (mostly), In the News, National, Northern Ireland, Person-Centred Care, Practical Advice, Quick Insights, Scotland, Standards, UK, Universal Interest, Wales | Tagged Apologising to Patients, BAPEN: British Association of Parenteral and Enteral Nutrition, British Association of Parenteral and Enteral Nutrition (BAPEN), Buckinghamshire Healthcare Trust, Candour, Candour: Safety and Improvement, Common Professional Standards (NMC / GMC), Consent, Consent: Patients and Doctors Making Decisions Together, Consequences of the Francis Inquiry Report, Culture Change in the NHS, Culture of Candour, Culture of Raising Concerns, Culture of Reflective Practice, Culture of Safety, Dehydration, Dehydration in Frail Older People, Duty of Candour, Ethical Considerations, Face to Face Explanations / Apologies from Doctors Nurses and Midwives, Freedom to Speak Up Report: Principle 1: Culture of Safety, Freedom to Speak Up Report: Principle 2: Culture of Raising Concerns, Freedom to Speak Up Report: Principle 7: Raising and Reporting Concerns, General Medical Council (GMC), GMC: General Medical Council, GMC’s Good Medical Practice, Good Medical Practice, Hampshire Hospitals Foundation Trust, Health and Social Care Services in Northern Ireland, Healthcare Quality Strategy for NHS Scotland, Honesty, Honesty and Transparency, Hospital Nurse Staffing and Quality of Patient Care, Hydration and Nutrition, Implications of the Francis Inquiry Report, Incident Reporting, Incidents Errors and Near Misses, Learning Culture, Learning From Mistakes, Misdiagnosis, Moderate Harm, National Health Service (Concerns Complaints and Redress Arrangements) (Wales) Regulations 2011, Near Misses, NHS Culture, NHS Patient Safety Culture, Nurse Staffing Levels, Nursing and Midwifery Council (NMC), Open and Honest Working Environment, Openness, Openness and Honesty When Things Go Wrong, Openness and Honesty When Things Go Wrong (GMC / NMC), Openness and Transparency, Patient Harms, Patient Safety, Professional Duty of Candour, Professional Duty of Candour: NMC's Nursing Case Studies, Professional Standards, Professional Standards and Ethics, Professional Standards of Practice and Behaviour for Nurses and Midwives, Prolonged Psychological Harm, Protection From Unfair Criticism Detriment or Dismissal, Repercussions From the Francis Inquiry Report, Reporting Culture in the NHS, Reporting Systems, Scottish Patient Safety Programme, Severe Harm, Severe Harm Attributable to Problems in Healthcare, Severe Harm Leading to Death, Statutory Duty of Candour, Statutory Duty of Candour For Care Organisations (UK), Transparency, Transparency and Public Trust, Transparent Learning Culture, Welsh Government’s Health and Care Standards Framework | 1 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

Staff Empowerment and Engagement in the NHS (King’s Fund)

Posted on July 20, 2014 by Dementia and Elderly Care News

Summary A recent King’s Fund report summarises case studies at four NHS trusts with high medical engagement. The aim is to assist organisations create a culture and framework in which doctors are encouraged and enabled to engage in the leadership … Continue reading →

Posted in Acute Hospitals, Charitable Bodies, Commissioning, For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), King's Fund, National, NHS, NHS Improvement, Practical Advice, Quick Insights, Standards, UK | Tagged Active Engagement, Barriers to Engagement, Barriers to Involvement, Berwick Review of Patient Safety, Center for Creative Leadership, Chris Ham: The King’s Fund, Clinical Engagement, Clinical Involvement in Policy Decisions, Clinical Leaders, Clinical Leadership, Clinical Policy Group (CPG), Collective Leadership, Collective Leadership for Health Care, Continuous Improvement, Continuous Learning, Continuous Learning Culture, Cross-Organisation Learning, Devolution (NHS Reform), Devolved Decision-Making, Doctors as Clinical Leaders, Education and Training, Employee Engagement, Empowerment, Engagement on Quality, Front Line Engagement, GE, Geisinger, Governance, Healthy Leadership Strategic Framework, IHI: Institute for Healthcare Improvement, Innovation and Improvement, Institute for Health Leadership: Department of Health in Western Australia, Institute for Healthcare Improvement, Institute for Healthcare Improvement (IHI), Institute of Clinical Leadership: University of Warwick Medical School, Inter Mountain, Jonkoping, Leadership Development, Learning From Mistakes, Learning From Others (Nationally and Internationally), Learning Organisations, Medical Engagement and Leadership, Medical Engagement: Checklist, Multi-Agency Senior Leadership Programme, Multi-Professional Clinical Leadership, New York Presbyterian, Northumbria Healthcare NHS Foundation Trust, Promise to Learn: Berwick Report, Quality Improvement, Quality Improvement Approaches, Reforming the NHS From Within: Beyond Hierarchy, Salford Royal NHS Foundation Trust, SDA Bocconi School of Management (Milan), Sharing Learning, Southern Health NHS Foundation Trust, Staff and Associate Specialist (SAS) Doctors Leadership Development Programme, Staff Empowerment, Staff Empowerment in the NHS, Staff Engagement, Staff Engagement in the NHS, Types of Clinical Leadership, University College London Hospitals (UCLH), University College London Hospitals NHS Foundation Trust, University of Warwick Medical School, Virgin Atlantic, Virginia Mason Institute, Windsor Leadership Trust | Leave a comment

Fit and Proper Persons Test Regulations / Statutory Duty of Candour / Fundamental Standards (Department of Health)

Posted on July 13, 2014 by Dementia and Elderly Care News

Summary Directors of NHS providers will have to meet a fit and proper person test from October 2014, subject to parliamentary approval. The Care Quality Commission (CQC) can insist on the removal of directors who fail this test. Statutory Duty … Continue reading →

Posted in Acute Hospitals, Commissioning, Department of Health, For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), National, NHS, Person-Centred Care, Quick Insights, Standards, UK, Universal Interest | Tagged Accountability, Barring List, Berwick Review of Patient Safety, Best Interests, Best Interests of Patients, Candour, Candour: Safety and Improvement, Care Quality Commission (CQC), Care Quality Commission’s (CQC’s) Regulation and Inspection of Care Providers, Communicating With Patients About Medical Errors, Compassionate Care, Complaints, Confidence, Consent, Consent to Treatment and CTOs, Consequences of the Francis Inquiry Report, Consultations on Fundamental Standards: Duty of Candour, Consultations on Fundamental Standards: Fit and Proper Persons Requirement for Directors, Corporate Accountability, Culture Change, Culture of Candour, Dalton Williams Review: Threshold for Duty of Candour, Dignity and Respect, Duty of Candour, Fit and Proper Person Test, Fit and Proper Person’s Test, Fit and Proper Persons Requirement for Directors, Francis Inquiry, Fundamental Standards, Good Governance, Government Policy, Grounds for Unfitness, Hard Truths, Harm, Harm Free Care, Harm Threshold, Harm Threshold for Adult Social Care, Health and Adult Social Care Providers, Health and Social Care Providers, Health Policy, Healthcare Providers, Healthy Living and Social Care: Red Tape Challenge, Improving Patient Safety, Improving the Safety of Patients in England, Incentivising Candour, Incident Disclosure, Incidents Errors and Near Misses, Informed Patient Consent, Inspection of Commissioners, Learning From Mistakes, Local Care Providers, Local Service Providers, Mental Capacity Act 2005, Mental Capacity and Best Interests, Mid Staffordshire NHS Foundation Trust, Misconduct and Mismanagement, National Reporting and Learning System (NRLS), New Start (CQC), NHS Complaints Process, NHS Constitution, NHS Culture, NHS Providers, No Harm Culture, NRLS Harm Definitions, Nutrition and Hydration, Nutritional Needs, Offences, Open Culture, Openness, Openness and Transparency, Patient Complaints, Patient Safety, Patient Safety Incidents, Patients First and Foremost, Penalties, Policy, Policy Development, Post-Paternalist Age, Premises and Equipment, Protecting Adults from Abuse or Neglect, Providers, Public Confidence, Quality Regulation Branch: Department of Health, Quality Regulation Team: Department of Health, Red Tape Challenge, Registration with the Care Quality Commission (Requirements), Repercussions From the Francis Inquiry Report, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Reporting Culture, Requirements for Registration with the Care Quality Commission, Safe Care and Treatment, Safe Staffing, Safeguarding Against Abuse, Service Providers, Staff Skills, Stafford Hospital, Standards of Care, Statutory Duty of Candour, Strengthening Corporate Accountability, Threshold for Duty of Candour, Transforming Care, Transparency, Transparency and Accountability, Wilful Neglect | 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

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