Tag Archives: NHS Patient Safety Culture

Quality Improvement: Strategies Needed to Reduce Preventable Patient Harm (NIHR Signal / BMJ / Future Healthcare Journal / WHO)

Posted on October 6, 2019 by Dementia and Elderly Care News

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) | 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, Drug Errors, Future Healthcare Journal, Health Services Research and Primary Care: University of Manchester, Honesty and Transparency, Hospital Patient Safety Strategies, 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, School of Medicine: University of Nottingham, Service Delivery and Safety (WHO), 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, WHO: World Health Organization, World Health Organization (Geneva), World Health Organization (WHO) | Leave a comment

System to Measure and Prevent Medication Errors Under Development (Department of Health and Social Care / EEPRU / BBC News)

Posted on May 12, 2018 by Dementia and Elderly Care 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) | 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 | Leave a comment

Medication Errors: an Open Learning Culture Recommended to Reduce Patient Harm (BBC News / Department of Health / EEPRU / Department of Health and Social Care)

Posted on February 25, 2018 by Dementia and Elderly Care News

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) | 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 | Leave a comment

Compassionate Leadership and Innovation in Health Care (King’s Fund / Health Foundation / NHS Leadership Academy)

Posted on May 9, 2017 by Dementia and Elderly Care News

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 →

The Foundations for a Patient-Centred NHS Learning Culture? (Department of Health / BBC News)

Posted on July 21, 2015 by Dementia and Elderly Care 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 →

Seven Day Working and Much More: Aiming for a More Patient-Centred, Transparent and Safe NHS (Department of Health)

Posted on July 17, 2015 by Dementia and Elderly Care News

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 | 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 | Leave a comment

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

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