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- Some Speculated / Potential Benefits of COVID-19 (JGCR / BBC Radio 4’s Rethink / BGS)
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Tag Archives: NHS Patient Safety Culture
Quality Improvement: Strategies Needed to Reduce Preventable Patient Harm (NIHR Signal / BMJ / Future Healthcare Journal / WHO / Staffordshire University)
Summary A recent review found that around 6% patients in healthcare settings (internationally) experience potentially preventable harm; with approximately 1 in 8 such cases resulting in severe harm, permanent disability or death “Six types of patient harm were identified: drug … Continue reading →
Posted in Acute Hospitals, Commissioning, Community Care, For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), Integrated Care, International, NHS, NHS England, NHS Improvement, NIHR, Non-Pharmacological Treatments, Person-Centred Care, Pharmacological Treatments, Quick Insights, Royal Wolverhampton NHS Trust, Systematic Reviews, UK, Universal Interest, World Health Organization (WHO)
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Tagged 10 Facts About Hospital Care (WHO), Avoidable Harm, Avoidable Hospital Mortality, Avoidable Mortality, Avoidable Patient Harm, BMJ, BMJ Publishing Group Ltd, British Medical Journal (BMJ), Centre for Pharmacoepidemiology and Drug Safety: University of Manchester, Clinical Quality Improvement, Clinical Safety Research: Imperial College London, Continuous Improvement, Continuous Learning and Improvement, Continuous Learning Culture, Division of Pharmacy and Optometry: University of Manchester, Division of Population Health: University of Manchester, Division of Primary Care: University of Nottingham, Dr Sarahjane Jones: Associate Professor in Patient Safety at Staffordshire University, Drug Errors, Future Healthcare Journal, Health Innovation Centre: Stafford Centre of Excellence for Healthcare Education (Staffordshire University), Health Services Research and Primary Care: University of Manchester, Honesty and Transparency, Hospital Patient Safety Strategies, Human Factors for Patient Safety: Staffordshire University, Imperial College London, Improving Patient Safety, Improving Safety Measurement Across Whole System, Information Sharing, Innovation and Improvement, Insight: Using Intelligence From Multiple Sources of Patient Safety Information, Lancashire Teaching Hospitals NHS Foundation Trust, Learning Culture, Learning from Deaths, LeDeR: Learning Disabilities Mortality Review, Lucie Musset: National Reporting and Learning System (NRLS), Medication Errors, Medication Errors and Adverse Drug Reactions, Medication Without Harm (WHO), Medicines Optimisation, National Institute for Health Research (NIHR), NHS Culture, NHS Culture Change, NHS Improvement Patient Safety Alerts, NHS Patient Safety Culture, NHS Patient Safety Strategy, NIHR DC: NIHR Dissemination Centre, NIHR Dissemination Centre, NIHR Greater Manchester Patient Safety Translational Research Centre, NIHR School for Primary Care Research: University of Manchester, NIHR Signal, Oxford Health NHS Foundation Trust, Oxford Healthcare Improvement, Patient Harm, Patient Harms, Patient Safety, Patient Safety Alerts, Patient Safety and Risk Management (WHO), Patient Safety Culture, Patient Safety Fact File (WHO), Prevalence of Patient Harm, Prevalence of Preventable Patient Harm, Preventable Patient Harm, QI Adoption and Spread Approach, Quality and Sustainability, Quality Improvement, Reducing Waste in the NHS, Research Into Safety in Health and Social Care Network (ReSNET), Research into Safety in health and social care Network (Staffordshire University - ReSNET), School of Medicine: University of Nottingham, Service Delivery and Safety (WHO), Staffordshire University, Systematic Reviews and Meta-Analyses, Ten Facts About Hospital Care (WHO), Transparent Learning Culture, Types of Preventable Patient Harm and Overall Patient Harm, UK General Medical Council, University of Manchester, University of Nottingham, University of Oxford, Vanda Carter: Practice Education Facilitator for Research at Royal Wolverhampton Hospitals NHS Trust, WHO: World Health Organization, World Health Organization (Geneva), World Health Organization (WHO), World Patient Safety Day, World Patient Safety Day (2020)
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System to Measure and Prevent Medication Errors Under Development (Department of Health and Social Care / EEPRU / BBC News)
Summary The Department of Health and Social Care now has a system to help identify, monitor and prevent medication errors. The aim is to help ensure the NHS becomes the safest healthcare system in the world, as well as avoiding … Continue reading →
Posted in Acute Hospitals, Commissioning, Community Care, Department of Health, Department of Health and Social Care (DHSC), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), In the News, Integrated Care, National, NHS, Pharmacological Treatments, Quick Insights, Standards, Statistics, UK, Universal Interest, World Health Organization (WHO)
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Tagged Adverse Drug Reactions, Adverse Drug Reactions (ADRs), Adverse Drug Reactions in the Elderly, Avoidable Admissions, Avoidable Harm, Avoidable Hospital Admissions, Avoidable Ill-Health, Avoidable Mortality, Avoidable Premature Mortality, Avoidable Rehospitalisations, Caroline Dinenage: Care Minister, Choosing Wisely, Choosing Wisely Campaign, Community Pharmacists, Continuous Learning Culture, Culture Change, Culture of Raising Concerns, Defences for Pharmacists: Accidental Dispensing Errors, Department of Health and Social Care (Formerly the Department of Health), Electronic Prescribing and Medicines Administration (EPMA), Electronic Prescribing Systems, ePACT2, Epidemiology and Statistics, Gastric Bleed Statistics, Global Patient Safety Challenge (WHO), Hospital Admissions, Hospital Electronic Prescribing and Medicines Administration (HePMA), Inappropriate Hospital Admissions, Learning Culture, Measurement and Prevention of Medication Errors, Medication Errors, Medication Errors and Adverse Drug Reactions, Medication Reviews, Medication Safety, Medication Safety Dashboard, Medication Without Harm (WHO), Medicines Optimisation, Medicines Optimisation Dashboard, Medicines Safety Programme (WHO), NHS Culture Change, NHS England Medicines Optimisation Intelligence Group, NHS Patient Safety Culture, NHS Specialist Pharmacy Service, NHS: Safest Healthcare System in the World (Ambition), No Harm Culture, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Without Gastro Protective Medicine, Openness and Honesty When Things Go Wrong, Openness and Transparency, Patient Safety, Patient Safety Improvement, Patient Safety Indicators, Patient Safety Strategies, Patients With Polypharmacy Risks, Pharmacist-Led Medication Reviews, Policy Research Unit in Economic Evaluation of Health and Care Interventions (EEPRU), Polypharmacy, Preventable Deaths in English Acute Hospitals, Preventable Hospital Admissions, Preventable Hospital Deaths, Preventable Hospital Mortality, Preventable Mortality, Preventing Avoidable Emergency Admissions, Primary Care Adverse Drug Reactions, Putting Patients First, Quality Improvement, Quality Improvement Culture, Reducing Inappropriate Polypharmacy, Reducing Litigation Costs, Reducing Waste in the NHS, Regular Medication Reviews, Report of the Short Life Working Group on Reducing Medication-Related Harm, Reporting Culture, Reporting of Incidents, Research on Medication Error, Royal Pharmaceutical Society (RPS), ScHARR: University of Sheffield, School of Health and Related Research (ScHARR): University of Sheffield, Short Life Working Group on Reducing Medication-Related Harm, Stop the Over-Medication of People With a Learning Disability or Autism (STOMP) Campaign, Transparency, Transparency and Accountability, Transparent Learning Culture, Unnecessary Hospital Admissions
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Medication Errors: an Open Learning Culture Recommended to Reduce Patient Harm (BBC News / Department of Health / EEPRU / Department of Health and Social Care)
Summary Medication errors, which include (i) wrong medications given, (ii) incorrect doses and (iii) delays in medication being administered, cause an estimated 700 deaths per year and might play a role in something between 1,700 to 22,300 further avoidable deaths. … Continue reading →
Posted in Acute Hospitals, BBC News, Commissioning, Community Care, Department of Health, Department of Health and Social Care (DHSC), For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), In the News, Integrated Care, Management of Condition, National, NHS, Pharmacological Treatments, Quick Insights, Standards, Statistics, UK, Universal Interest, World Health Organization (WHO)
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Tagged Acute Care and Quality, Acute Care and Workforce, Adult Psychiatric Intensive Care Services, Adverse Drug Reactions, Adverse Drug Reactions (ADRs), Adverse Drug Reactions in the Elderly, BBC Health News, Blame Culture, Care Home Culture, Care Home Environments, Care Homes, Centre for Health Economics: University of York, Choosing Wisely Campaign, Choosing Wisely in the NHS, CHUMS Study, Clinical Pharmacists, Clinical Responsibility for Patients (Choosing Wisely and New Deal), Community Pharmacists, Continuous Learning Culture, CQC Investigations and Quality Policy, Culture and Behaviour Change, Culture and Leadership, Culture Change, Culture of Raising Concerns, Department of Health Policy Research Programme, Division of Population Health Health Services Research and Primary Care: University of Manchester, Electronic Prescribing and Medicines Administration (EPMA), Electronic Prescribing Systems, EQUIP Study, Former Health Secretary Jeremy Hunt, Global Patient Safety Challenge (WHO), HePMA, Hospital E-Prescribing and Medicines Administration, Hospital Electronic Prescribing and Medicines Administration (HePMA), Hospital Pharmacists, Learning Culture, Making Choices Together (Previously Choosing Wisely Wales), Manchester Centre for Health Economics: University of Manchester, Medication Errors, Medication Errors and Adverse Drug Reactions, Medication Without Harm (WHO), Medicines Safety Programme (WHO), Medicines Value Programme (NHS England), NHS Culture, NHS Culture Change, NHS Patient Safety Culture, NHS Specialist Pharmacy Service, No Harm Culture, Old Age Psychiatry, Open and Transparent Culture, Openness, Openness and Collaboration, Openness and Honesty When Things Go Wrong, Openness and Transparency, Partnering with Patients and Families, Patient and Family Engagement, Patient and Public Engagement (PPE), Patient and Public Involvement, Patient and Public Involvement (PPI), Patient Engagement, Patient Engagement Strategies, Patient Harm, Patient Harms and Harm Free Care, Patient Safety, Patient Safety Champions, Patient Safety Improvement, Patient Safety Indicators, Patient Safety Strategies, Patients With Polypharmacy Risks, Pharmacist Buddy Scheme (County Durham and Darlington NHS Foundation Trust), Pharmacist-Led Information Technology Intervention (PINCER), Pharmacists, PINCER Intervention, Policy Research Programme (PRP), Policy Research Unit in Economic Evaluation of Health and Care Interventions (EEPRU), Polypharmacy, Potentially Preventable Complications in Hospitalis, PREPARE: Partnership for Responsive Policy Analysis and Research, PRescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) Study, Prescription Errors in Psychiatry, Preventable Deaths in English Acute Hospitals, Preventable Hospital Deaths, Preventable Hospital Mortality, Preventable Mortality, Primary Care Adverse Drug Reactions, PROTECT Programme, Putting Patients First, Quality Improvement Culture, Reducing Inappropriate Polypharmacy, Reducing Litigation Costs, Report of the Short Life Working Group on Reducing Medication-Related Harm, Reporting Culture, Reporting of Incidents, Research on Medication Error, Rt Hon Jeremy Hunt MP: Former Secretary of State for Health and Social Care, ScHARR: University of Sheffield, School of Health and Related Research (ScHARR): University of Sheffield, SDM: Shared Decision Making, Secondary Care Adverse Drug Reactions, Serious Mistakes, Severe Harm, Shared Care and Education, Shared Decision-Making, Short Life Working Group (SLWG), Short Life Working Group on Reducing Medication-Related Harm, Stop the Over-Medication of People With a Learning Disability or Autism (STOMP) Campaign, Transparency, Transparency and Accountability, Transparent Learning Culture, UK Department of Health Policy Research Programme, United States National Coordinating Council for Medication Error Reporting and Prevention, University of Manchester, University of Sheffield, University of York, University of York Centre for Health Economics (CHE), WHO Domain: Health Care Professionals, WHO Domain: Medicines, WHO Domain: Patients and the Public, WHO Domain: Systems and Practice of Medication, WHO Domains, WHO Global Patient Safety Challenge
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Compassionate Leadership and Innovation in Health Care (King’s Fund / Health Foundation / NHS Leadership Academy / Novartis)
Summary Four aspects of organisational culture which might better promote innovative and high-quality care in the NHS are said to comprise: An inspiring vision and strategy. A culture of inclusion and participation. More open team and cross-boundary working. Greater support … Continue reading →
Posted in Acute Hospitals, Charitable Bodies, Commissioning, Community Care, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), Health Education England (HEE), Health Foundation, Integrated Care, King's Fund, Local Interest, National, NHS, NHS Improvement, Person-Centred Care, Quick Insights, Standards, UK, Universal Interest
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Tagged Accelerating Innovation, Accountable Care Organisations (ACOs), Adopters and Adoption of Innovation, Adoption of Innovations, Advancing Quality Alliance (AQuA), AQuA (NHS Organisation), Aravind Eye Care Systems, Autonomy for Staff Innovation, Barriers to Innovation, Birmingham Women’s and Children’s NHS Foundation Trust, Cascading Leadership Pilot, Cascading Leadership: Leadership in Voluntary and Community Sector, Collaboration, Collaborative Care, Collaborative Leadership, Collaborative Working, Collective Leadership, Community-Based Dementia Care Networks, Compassion: the Core NHS Cultural Value, Compassionate Leadership, Compassionate Leadership and Innovation, Compassionate Leadership: Cultural Elements, Continuous Improvement, Cross-Boundary Care Pathways, Cross-Organisation Learning, Cross-Sector Collaboration, Cross-Sector Partnerships, Culture and Leadership, Culture Change, Culture of Care, Culture of Empowerment and Support, Culture of Safety, Culture: Lack of Leadership Support for Innovation (Barriers to Innovation), Culture: Provider/Commissioner Risk Aversion (Barriers to Innovation), Culture: Silo Thinking in System (Barriers to Innovation), Developing People - Improving Care: National Framework for Leadership Development (NHS Improvement), Diffusion of Innovation, Empathy in Design (IDEO), End to Silo Working, Extreme Teaming: Delivering Integrated Care, Facilitating Large Scale Change Skills Development Programme, Fearless Organisations: Creating Psychological Safety for Teaming Failing and Learning, Freeing the NHS to Innovate, Healthcare Leadership Model, HEE: Health Education England, High-Quality Home Care (Buurtzorg: Netherlands), Horizon-Scanning, Improving Patient Safety, Inclusion, Inclusiveness, Inspiring Vision and Strategy, Institute for Healthcare Improvement (IHI), Inter-Teamworking, Leadership and Organisational Development Team: King’s Fund, Leadership Development in NHS-Funded Services, Leadership for Culture Change, Leading Large Scale Change: A Practical Guide, Learning Culture, Narayana Health, National Improvement and Leadership Development Board (NILD), New Care Models, New Models of Care, NHS Culture, NHS Culture Change, NHS Healthcare Leadership Model, NHS Healthcare Leadership Model: Connecting Services, NHS Healthcare Leadership Model: Developing Capability, NHS Healthcare Leadership Model: Engaging the Team, NHS Healthcare Leadership Model: Evaluating Information, NHS Healthcare Leadership Model: Holding to Account, NHS Healthcare Leadership Model: Influencing for Results, NHS Healthcare Leadership Model: Inspiring Shared Purpose, NHS Healthcare Leadership Model: Leading With Care, NHS Healthcare Leadership Model: Nine Dimensions of Leadership Behaviour, NHS Healthcare Leadership Model: Sharing Vision, NHS Improvement’s National Framework for Leadership Development, NHS Leadership Academy, NHS Leadership Academy (NHS LA), NHS Leadership Academy Moved From NHS England to Health Education England, NHS Patient Safety Culture, NHS Quest, No Harm Culture, Novartis Pharmaceuticals UK, Novartis), Open Culture, Organisational Culture, Patient Safety, Patient-Centred Culture, Positive Culture, Positive Inclusion and Participation, Problem-Solving and Innovation, Professional Silos, Professor Amy Edmondson: Novartis Professor of Leadership and Management at Harvard Business School, QI Culture, Quality Improvement, Research Culture, Sankara Eye, Shaping Culture, Sustainability and Transformation Plans (STPs), Sustainable Improvement Team and Horizons Team (NHS England), Sustainable Improvement Team: NHS England, Teamworking, VUCA World: Volatile Uncertain Complex Ambiguous
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The Foundations for a Patient-Centred NHS Learning Culture? (Department of Health / BBC News)
Summary This “Learning Not Blaming” report presents the government’s response to (i) the Francis Freedom to Speak Up review, (ii) the Morecambe Bay Investigation, and (iii) the Public Administration Select Committee’s report on clinical incidents. The common theme for addressing … Continue reading →
Posted in Acute Hospitals, Commissioning, Community Care, Department of Health, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), In the News, Integrated Care, Local Interest, Management of Condition, National, NHS, NHS Improvement, Non-Pharmacological Treatments, Patient Care Pathway, Person-Centred Care, Quick Insights, Standards, UK, Universal Interest
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Tagged Authority Gradients vs Freedom to Speak Up, Aviation Industry, Avoidable Harm, Avoidable Mortality, Avoidable Premature Mortality, BBC Leicester News, BBC Panorama, BBC Panorama: Doctors on Trial, Capacity and Capability of Regulators, Care Quality Commission, Care Quality Commission (CQC) Inspection Regime, Care Seven Days a Week, Charlie Massey: Chief Executive of GMC, Clinical Incident Investigations, Clinical Incidents in the NHS, Clinical Risk Recognition and Planning, Comfort Seeking Organisations, Commons Public Administration Select Committee (PASC), Complaints and Raising Concerns, Complaints Handling, Complexity in the Complaints System, Consequences of the Francis Inquiry Report, Continuous Learning Culture, Corporate Self-Interest (Ahead of Patients), Cover-Ups (Attributed), Culture, Culture and Leadership, Culture Change in the NHS, Culture of Candour, Culture of Safety, Cumbria, Cumbria Partnership NHS Foundation Trust, Delayed Problem Recognition, Doctor Hadiza Bawa-Garba, Dr Bill Kirkup CBE, Dr Mike Durkin: NHS England’s Director of Patient Safety, Dr Mike Durkin: Patient Safety Investigation Service, Duty of Candour, Elevated Weekend Hospital Mortality, Five Year Forward View, Five Year Forward View (NHS England), Former Health Secretary Jeremy Hunt, Francis Freedom to Speak Up Report, Freedom to Speak Up (FTSU) Report, Freedom to Speak Up Guardian, Freedom to Speak Up Guardians, Freedom to Speak Up Report, 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, Freedom to Speak Up? (Whistleblowing Review), Furness General Hospital, Furness General Hospital Dementia Unit, Furness General Hospital in Cumbria, Furness General Hospital: Ramsay Unit, Health Systems in Transition (HiT), Healthwatch, Honesty and Transparency, Hospital Mortality, Hospital Mortality Rates, House of Commons Public Administration Select Committee (PASC), Implications of the Francis Inquiry Report, Improving Services For Patients: Not Defending the System, Incident Reporting, Independent National Officer, Independent National Officer (INO), Independent Patient Safety Investigation Service, Independent Patient Safety Investigation Service (IPSIS), Intelligent Transparency, IPSIS: Independent Patient Safety Investigation Service, Just Culture, Learning Culture, Learning for Improvement, Learning from Complaints, Learning From Errors and Failures in Care, Learning Not Blaming, Listening to Patients Families and Staff, Local Freedom to Speak Up Guardians, MBRRACE-UK (Mothers and Babies – Reducing Risk Through Audits and Confidential Enquiries Across the UK), Monitor, Morecambe Bay Inquiry, Morecambe Bay Investigation Report, Mortality at the Weekend, National Clinical Assessment Service (NCAS), Negative Culture, Never Events, NHS Accountability, NHS Corporate Self-Interest, NHS Culture, NHS England Never Events Taskforce, NHS Five Year Forward View (5YFV), NHS Managerial Self-Interest, NHS Micro-Climates, NHS Patient Safety Culture, NHS Trust Development Authority (NHS TDA), NHS Trust Development Authority (NTDA), NHS Trust Development Authority (TDA), No Harm Culture, Open and Honest Incident Reporting, Open and Supportive Culture, Openness, Over-Complexity, Over-Reliance on External Approval, Over-Reliance on External Judgments, Over-Reliance on Judgments of Others, Panorama (BBC TV), Panorama: Doctors on Trial, Parliamentary and Health Service Ombudsman, Patient Safety, Patient Safety in the NHS, Police: Complaints, Preventable Hospital Mortality, Problem Sensing, Problem Sensing Organisations (Versus Comfort Seeking Organisations), Public Administration Select Committee (PASC), Public Administration Select Committee Report into Clinical Incident Investigations, Recommendations for the University Hospitals of Morecambe Bay NHS Foundation Trust, Reducing Complexity, Reduction in Bureaucracy, Regulating Healthcare Systems, Regulating Healthcare Systems: Monitor, Regulation, Regulators, Regulators Sharing Information, Regulatory and Professional Bodies, Regulatory Gaps in Healthcare, Regulatory System, Repercussions From the Francis Inquiry Report, Report Into Maternity Care at Cumbria’s Furness General Hospital, Report of the Morecambe Bay Investigation, Reporting Culture, Reporting Mistakes, Rhona Flin: Aberdeen University, Rt Hon Jeremy Hunt MP: Former Secretary of State for Health, Scrutiny of Perinatal and Maternal Deaths, Second Mid Staffs: Furness General Hospital Parallels, Serious and Untoward Incidents (SUIs), Service Redesign, Seven Day Care in England, Seven Day Services, Small Business Enterprise and Employment Act 2015 (SBEEA), Speaking Up: Resolving NHS Complaints and Preventing Problems Recurring, Surgical Never Events, Target Culture, Target-Chasing (Hitting the Target Missing the Point), Transparency, Transparency and Accountability, Transparent Learning Culture, University Hospitals of Morecambe Bay NHS Trust, Unnecessary In-Hospital Deaths, User Complaints, Valuing Complaints, Weekend Effect, Weekend Mortality Rates, Weekend Services, Weekend Working, Whistleblowing, Workplace Culture
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Seven Day Working and Much More: Aiming for a More Patient-Centred, Transparent and Safe NHS (Department of Health)
Summary Health Secretary Jeremy Hunt has re-asserted his intention to pursue the New Deal for GPs, and seven day NHS services generally; if necessary by removing the weekend working opt-out in new hospital consultants’ contracts. NHS Improvement Plans for the … Continue reading →
Posted in Acute Hospitals, Commissioning, Community Care, Department of Health, For Carers (mostly), 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, NHS Improvement, Northern Ireland, Nuffield Trust, Patient Care Pathway, Person-Centred Care, Personalisation, Quick Insights, Scotland, Standards, Statistics, UK, Universal Interest, Wales
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Tagged Alzira (Spain), Apollo (India), BBC Northern Ireland, BBC Northern Ireland Health News, BBC Wales, Booking Appointments, British Medical Association, Care Seven Days a Week, Clinical Incident Investigations, Competition Based on Patient Choice, Consequences of the Francis Inquiry Report, Continuous Learning Culture, Crowd Effect (Crowd Psychology), Crowd Herding, Culture and Leadership, Culture Change in the NHS, Culture of Safety, DDRB Recommendation for Removal of Consultant Weekend Opt-Out, Department of Cardiothoracic Surgery: University Hospitals Birmingham NHS Foundation Trust, Department of Informatics: University Hospitals Birmingham NHS Foundation Trust, Department of Primary Care and Population Health: University College London, DevoManc, Digital Innovation, Digital Innovations in Health, Dr Dan Poulter (Former Conservative Health Minister), Dr Johann Malawana: Former Chair of BMA Junior Doctors Committee, Dr Mike Durkin: NHS England’s Director of Patient Safety, Dr Mike Durkin: Patient Safety Investigation Service, Electronic Booking, Elevated Weekend Hospital Mortality, Extra Payments for Unsociable Working, Farr Institute of Health Informatics Research: University College London, Financial Sustainability in the NHS, Five Year Forward View, Five Year Forward View (NHS England), Former Health Secretary Jeremy Hunt, Francis Freedom to Speak Up Report, Freedom to Speak Up Report, Freedom to Speak Up? (Whistleblowing Review), Gary Caplin: Chief Executive of Virginia Mason Hospital (Seattle), Greater Manchester, Healthcare Financial Management Association, Healthcare Financial Management Association (HFMA), HFMA: Healthcare Financial Management Association, Honesty and Transparency, Implications of the Francis Inquiry Report, Independent National Officer, Independent National Officer (INO), Independent Patient Safety Investigation Service, Intelligent Transparency, International Buddying Programme, Junior Doctors Balloted on Seven Day Working Terms and Conditions, Junior Doctors: Contract Dispute of 2015, Kaiser Permanente, Keogh Review, Learning Culture, Learning Not Blaming, Lord Rose Report into NHS Leadership, Lord Rose Report on Leadership in the NHS, Lord Rose Report: Better Leadership for Tomorrow, Martha Lane Fox, Mayo Clinic, Medical Director of NHS England: Professor Sir Bruce Keogh, Medical Directorate: NHS England, Monitor, Morecambe Bay Investigation Report, Mortality at the Weekend, Never Events, New Deal, New Deal for General Practice, New Deal for Primary Care, News Manipulation and Intransigence, NHS Culture, NHS England, NHS Five Year Forward View (5YFV), NHS Leadership Academy Moved From NHS England to Health Education England, NHS National Information Board, NHS Patient Safety Culture, NHS Pay Review Body, NHS Pay Review Body (NHSPRB), NHS Services Seven Days a Week, NHS Trust Development Authority (NHS TDA), NHS Trust Development Authority (NTDA), NHS Trust Development Authority (TDA), Nigel Edwards: Nuffield Trust, No Harm Culture, Open and Supportive Culture, Opt-Outs (Consultant Contracts), Oral Statement to Parliament: Improving Safety Culture in the NHS (July 2015), Orchestrated Intransigence, Patient Choice, Patient Power 2.0, Patient Safety, Patient Safety in the NHS, Policy Issues Posed by Devolution, Procurement Patient Choice and Competition Regulations, Professional Standards, Professor Sir Bruce Keogh, Public Administration Select Committee Report into Clinical Incident Investigations, Public Administration Selection Committee, Quality and Outcomes Research Unit: University Hospitals Birmingham NHS Foundation Trust, QUORUM Metric for Comparing Hospital Death Rates, RCGP, Reduction in Bureaucracy, Repercussions From the Francis Inquiry Report, Report of the Morecambe Bay Investigation, Review Body on Doctors’ and Dentists’ Remuneration, Review Body on Doctors’ and Dentists’ Remuneration (DDRB), Royal College General Practice (RCGP), Rt Hon Jeremy Hunt MP: Former Secretary of State for Health, Scottish Government, Service Redesign, Seven Day Care in England, Seven Day NHS Pledge: Problem of Resources, Seven Day NHS Pledge: Problem of Staff Shortages, Seven Day NHS Pledge: Problem of Unwillingness or Incapacity for Doing More With Less, Seven Day NHS Pledge: Problem of Workforce Overload, Seven Day NHS Pledge: Problems Identified in Leaked Confidential Department of Health Review, Seven Day Services, Seven-Day GP Access, Seven-Day Hospital Services, Seven-Day NHS Services, Seven-Day Opening, Seven-Day Working, Simon Hamilton: Northern Ireland's Health Minister, Survivorship Models, Sustainability, Sustainable Funding, Sustainable Health and Care Services, System Re-Design, Transparency, Transparency and Accountability, Transparency and Devolution, Transparent Learning Culture, University College London, University Hospitals Birmingham NHS Foundation Trust, Unsociable Hours Payments, Virginia Mason Hospital: Seattle, Weekend Effect, Weekend Mortality Rates, Weekend Services, Weekend Working, Welsh Government
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Professional Duty of Candour: Openness and Honesty When Things Go Wrong (NMC / GMC / Nursing Times / BBC 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
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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
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Patient Safety Risks: Focus on Patient Handover and Patient Discharge From Secondary Care (NHS England)
Summary NHS England has issued a patient safety alert in the effort to improve the quality and timeliness of communication with primary and social care when patients are discharged from hospital. Read more: NHS England. Patient safety alert on risks arising from breakdown … Continue reading →
Posted in Acute Hospitals, Community Care, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), Integrated Care, Management of Condition, Mental Health, Models of Dementia Care, National, NHS, NHS England, Patient Care Pathway, Person-Centred Care, Personalisation, Quick Insights, Standards, UK, Universal Interest
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Tagged Avoidable Harm, Avoidable Mortality, Avoidable Rehospitalisations, Breakdowns or Failures in Communication, Clinical Quality Improvement, CMHT: Community Mental Health Teams, Communication During Handovers, Community Mental Health Teams, Continuing Care Team (CCT), Deficient Checking and Oversight, Department of Primary Care and Public Health: Imperial College London, Discharge, Discharge and Out of Hospital Care, Discharge Coordination, Discharge From Acute and Mental Health Trusts, Discharge Information, Discharge Planning, Dysfunctional Patient Flow, Equipment-Related Errors, Failure of Prevention, Failure to Recognise Deterioration, Handover, Handover Records, Hospital Discharge, Imperial College London, Improving Patient Safety, Inpatient Falls, Institute of Global Health Innovation: Imperial College London, Integrated Discharge Process, Mental Health Trusts, Mismanagement of Deterioration, National Reporting and Learning System (NRLS), NHS England (Patient Safety), NHS England Patient Safety Domain, NHS England Patient Safety Steering Group, NHS England Primary Care Patient Safety Expert Group, NHS Patient Safety Culture, Patient Discharge, Patient Discharge From Secondary Care, Patient Flows, Patient Handovers, Patient Safety, Patient Safety Alert on Breakdown and Failure to Act: Communication During Handover at Discharge From Secondary Care, Patient Safety Alerts, Patient Safety First (PSF), Patient Safety in the NHS, Patient Safety Incidents, Patient-Safety-Related Hospital Deaths in England, Post-Discharge Support, Quality Improvement, Reducing Early Hospital Readmissions, Review of NRLS Incidents at Discharge From Acute and Mental Health Trusts, Stage 1 Patient Safety Alert
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Care Quality Commission: Special Measures Approach for Care Homes? (BBC News)
Summary The system of special measures, designed to improve failing hospitals in England, is likely to be extended to care homes. Full Text Link Reference Triggle, N. (2014). Hospital failure regime extended to care homes. London: BBC Health News, July … Continue reading →
Posted in BBC News, Community Care, CQC: Care Quality Commission, For Carers (mostly), For Nurses and Therapists (mostly), For Social Workers (mostly), In the News, Management of Condition, National, Person-Centred Care, Quick Insights, Standards, UK, Universal Interest
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Tagged Avoidable Harm, BBC Health News, Buddying Schemes, Care Home Assessments, Care Home Inspections, Care Home Market, Care Home Regulation, Care Home Sector, Care Homes, Care Quality Commission (CQC), Compassion and Care, Compassionate Care, Culture Change, Culture of Zero-Harm, Dementia Care in Care Homes, Dignity and Respect, Failing Care Homes, Failing Hospitals, Human Rights in Care Homes, Improving Patient Safety, Improving Standards in Care Homes, Independent Scrutiny, Living Well in Care Homes, Management Changes, National Care Association (NCA), NHS Culture, NHS Patient Safety Culture, NHS Safe Staffing, No Harm Culture, Nurse Staffing Levels, Open Culture, Openness and Transparency, Organisational Culture, Patient Safety, Patient-Centred Culture, Professor Sir Mike Richards: Former Chief Inspector of Hospitals (CQC), Quality Ratings, Rating Systems, Safe Staffing, Safeguarding Adults in Care Homes, Scrutiny, Special Measures, Transparency, Transparency and Public Trust
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Professional Standards for Hospital Pharmacy Services (Royal Pharmaceutical Society)
Summary The Royal Pharmaceutical Society (RPS) have updated their “Professional Standards for Hospital Pharmacy Services”, in light of the Francis Inquiry report . Updates to this document place more emphasis on increasing patient involvement and feedback in the development of services. … Continue reading →
Posted in Commissioning, For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), Integrated Care, National, NHS, Pharmacological Treatments, Practical Advice, Quick Insights, Standards, UK
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Tagged Aston University, Berwick Review, Berwick Review of Patient Safety, Birmingham Children’s Hospital (BCH), Cambridge University Hospitals (CUH), Cambridge University Hospitals NHS Foundation Trust, Care Episodes, Central Manchester University Hospitals NHS Foundation Trust, Chief Pharmacists, Chronic Medication Service, Clinical Leadership, Consequences of the Francis Inquiry Report, Custom-Made Medicines, Discharge Medicines Review Service, Dispensing, Distribution Storage and Unused Medicines, Education and Training, Effective Use of Medicines, European Association of Hospital Pharmacists, European Working Time Directive (EWTD), Francis Inquiry Report, Future Hospital Commission, General Pharmaceutical Council, Governance, Hospital Pharmacies, Hospital Pharmacies: Seven Day Services, Hospital Pharmacists, Hospital Pharmacy Services, Implications of the Francis Inquiry Report, Information About Medicines, Integrated Transfer of Care, International Pharmaceutical Federation, International Pharmaceutical Federation (FIP), Joined-Up Hospital and Community Pharmacy Services, Labelling, Leadership, Leadership Competency Framework for Pharmacy Professionals, Local Approaches to Seven Day Pharmacy Services, Medication Adherence, Medicines Adherence, Medicines Expertise, Medicines Policy, Medicines Procurement, Mid Staffordshire NHS Foundation Trust Inquiry, National Advisory Group on the Safety of Patients in England, New Medicine Service, New Model of Care: Future Hospital Commission, NHS England’s Seven Days a Week Forum, NHS Patient Safety Culture, NHS Services: Seven Days a Week Forum, Operational Leadership, Patient Experience, Patient Focus, Patient Needs, Patient Outcomes, Patient Preference and Adherence, Pharmacy Workforce and Ways of Working, Primary Care and Community Pharmacy Network, Professional Leadership, Professional Responsibilities, Professional Standards, Professional Standards for Hospital Pharmacy Services, Putting Patients First, Repercussions From the Francis Inquiry Report, Royal College of Physicians’ Future Hospital Commission (RCP FHC), Royal Pharmaceutical Society, RPS Leadership Competency Framework for Pharmacy Professionals, RPS Professional Standards for Public Health Practice for Pharmacy, Safe Systems of Care, Safe Use of Medicines, Seven Day Pharmacy Services, Seven Day Services in Hospital Pharmacy, Strategic Leadership, Supply of Medicines, Targeted Medicines Use Reviews, UK Clinical Pharmacy Association, Walsall Healthcare NHS Trust, Week-Round NHS Services, Weekend Working, Workforce Development, Workforce Issues, Working Evenings and Weekends
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