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- International Perspectives on the Possible Impact of the COVID-19 Pandemic and Lockdown on Abuse of the Elderly (JGCR / American Journal of Geriatric Psychiatry / JAGS)
- Updates Relating to the Lancet Commission on Dementia Prevention, Intervention, and Care (Lancet / Alzheimer’s Research and Therapy / Alzheimer’s and Dementia)
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- Some Speculated / Potential Benefits of COVID-19 (JGCR / BBC Radio 4’s Rethink / BGS)
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Tag Archives: Reporting Culture
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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Latest NHS Whistleblowing Policy (NHS Improvement)
Summary NHS Improvement has released a summary of NHS whistleblowing policy, in the form of a practical handbook. The aim is to promote an open and supportive culture which encourages staff to raise concerns about patient care quality or safety … Continue reading →
Posted in Commissioning, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), Local Interest, National, NHS, NHS Improvement, Quick Insights, Standards, UK, Universal Interest
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Tagged Accountability, Advancing Change Team, Avoidable Harm, Behaviours to Enable Whistleblowing, CHKS Ltd, Corporate Self-Interest (Ahead of Patients), Culture Change, Culture Change in Health and Care, Culture Change in the NHS, Culture Free From Bullying, Culture of Raising Concerns, Culture of Reflective Practice, Culture of Safety, Culture of Valuing Staff, Data Quality in England (CHKS), Defensive Culture, Francis Freedom to Speak Up Report, Freedom and Responsibility to Speak Up (Francis Review Whistleblowing), Freedom to Speak Up (FTSU), Freedom to Speak Up Guardian, Freedom to Speak Up Guardians, Freedom to Speak Up Report, Freedom to Speak Up Report: Principle 10: Training, Freedom to Speak Up Report: Principle 11: Support, Freedom to Speak Up Report: Principle 12: Support to Find Alternative Employment in the NHS, Freedom to Speak Up Report: Principle 13: Transparency, Freedom to Speak Up Report: Principle 14: Accountability, Freedom to Speak Up Report: Principle 15: External Review, Freedom to Speak Up Report: Principle 16: Coordinated Regulatory Action, Freedom to Speak Up Report: Principle 17: Recognition of Organisations, Freedom to Speak Up Report: Principle 18: Students and Trainees, Freedom to Speak Up Report: Principle 19: Primary Care, Freedom to Speak Up Report: Principle 1: Culture of Safety, Freedom to Speak Up Report: Principle 20: Legal Protection, Freedom to Speak Up Report: Principle 2: Culture of Raising Concerns, Freedom to Speak Up Report: Principle 3: Culture Free From Bullying, Freedom to Speak Up Report: Principle 4: Culture of Visible Leadership, Freedom to Speak Up Report: Principle 5: Culture of Valuing Staff, Freedom to Speak Up Report: Principle 6: Culture of Reflective Practice, Freedom to Speak Up Report: Principle 7: Raising and Reporting Concerns, Freedom to Speak Up Report: Principle 8: Investigations, Freedom to Speak Up Report: Principle 9: Mediation and Dispute Resolution, Freedom To Speak Up Review (Sir Robert Francis QC), Freedom to Speak Up Self-Review Tool, Freedom to Speak Up: Guidance for NHS Trust and NHS Foundation Trust Boards, Freedom to Speak Up? (Whistleblowing Review), FTSU Guardian, FTSU Guardian Reports, Hospital Mortality Rates, Implications of the Francis Inquiry Report, Incident Reporting, Independent National Officer, Independent National Officer (INO), Independent National Whistleblowing Officer, Independent Patient Safety Champion, Independent Staff Concerns Advocate, Inspections and Bureaucracy, Intensive Support Teams, Investigations, Leadership for Culture Change, Legal Protection, Lives Ruined by Poor Handling of Staff Raising Concerns, Mid Staffordshire NHS Foundation Trust, Monitor, National Guardian’s Office, National Reporting and Learning System, NHS Corporate Self-Interest, NHS Culture, NHS Managerial Self-Interest, NHS TDA: NHS Trust Development Authority, NHS Trust Development Authority (NHS TDA), NHS Trust Development Authority (NTDA), NHS Trust Development Authority (TDA), NHS Whistleblowing Policy, Open and Honest Incident Reporting, Open Culture, Openness, Oversight and Monitoring, Patient Safety, Quality Improvement, Raising and Reporting Concerns, Raising Concerns, Raising Concerns (Whistleblowing) NHS Policy, Reduction in Bureaucracy, Reflective Practice, Regulation, Repercussions From the Francis Inquiry Report, Reporting Culture, Reporting Culture in the NHS, Royal Wolverhampton NHS Trust, Verita, Verita: Improvement Through Investigation, Vision for Raising Concerns in NHS, Well-Led Framework for Governance Reviews, Whistleblowing, Whistleblowing in the NHS, Whistleblowing Protection for Doctors in Training
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More on Patient Safety Concerns (BBC News / CQC)
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 →
Posted in Acute Hospitals, BBC News, Commissioning, Community Care, CQC: Care Quality Commission, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), In the News, Integrated Care, Local Interest, Mental Health, National, NHS, Person-Centred Care, Quick Insights, Standards, Statistics, UK, Universal Interest
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Tagged Acute Care, Acute Hospitals, Adult Social Care, Adult Social Care in England, Adult Social Care Ratings by Service Type, Adult Social Care Services, Adult Social Care: Market Oversight, Agency for Healthcare Research and Quality, Agency for Healthcare Research and Quality (AHRQ) Patient Safety Glossary, AHRQ, AHRQ Patient Safety Net, Barking, Barts Health NHS Trust, Basildon and Thurrock University Hospitals NHS Foundation Trust, BBC Health News, Buckinghamshire Healthcare NHS Trust, Burton Hospitals NHS Foundation Trust, Care Home Environments, Care Home Inspections, Care Home Sector, Care Homes, Care Homes Wellbeing, Care Homes. Nursing Homes, Care Quality Commission, Care Quality Commission (CQC), Care Quality Commission Inspection Ratings, Care Quality Commission New Inspection Ratings System, Care Requiring Improvement, Care Staffing: Capacity and Capability, Caring, Colchester Hospital University NHS Foundation Trust, Commissioning for Outcomes, Commissioning for Quality, Community Social Care, Competent and Capable Staff, Continuous Learning and Improvement, Continuous Learning Culture, CQC Hospital Inspections, CQC Inspection Questions (Safe Effective Caring Responsive Well-Led), CQC Inspections of GP Surgeries, CQC Recognition of Well-Led Organisations, Cross-Organisation Learning, Dementia Care, Domiciliary Care Agencies, East Kent Hospitals University NHS Foundation Trust, East Lancashire Hospitals NHS Trust, Encouraging Improvement, Equality, Frimley Park Hospital NHS Foundation Trust, George Eliot Hospital NHS Trust, Good Care, GP Inspections, GP Practices, GP Surgeries, Havering and Redbridge University Hospitals NHS Trust, Health and Adult Social Care, Health and Care, Health and Social Care, Heatherwood and Wexham Park Hospitals NHS Foundation Trust, High Quality Care, Hinchingbrooke Health Care NHS Trust, Home Care Services, Home Care Standards, Hospital Inspections, Improving Patient Safety, Inadequate Care, Inclusion Healthcare Social Enterprise in Leicester, Innovation, Inspections, Inspections by CQC, Leadership, Learning Culture, Learning From Mistakes, Local Variations, Medway NHS Foundation Trust, Mental Health Services, Multi-Disciplinary Team (MDT), Multi-Disciplinary Working, Multidisciplinary Teamwork, New Ratings System (CQC), NHS Safe Staffing, Norfolk and Suffolk NHS Foundation Trust, North Cumbria University Hospitals NHS Trust, North Lincolnshire and Goole NHS Foundation Trust, Nursing and Residential Homes, Nursing Homes, Open and Transparent Culture, Outstanding Care, Patient Safety, Patient Safety Glossary, Patient Safety Improvement, Patient Safety in the NHS, Patient Safety Indicators, Patient Safety Net (PSNet), Patient Safety Net (PSNet)'s Patient Safety Glossary, Peterborough and Stamford Hospitals NHS Foundation Trust, Primary Medical Services, Private Healthcare Information Network, Quality Improvement, Ratings, Ratings Grid For Acute Hospitals, Re-Inspections Drive Improvement, Reporting Culture, Reporting Culture in the NHS, Residential Homes, Resilience, Responsive, Safe (CQC Inspection Question), Safe Staffing, Safety, Safety and Effectiveness, Salford Royal NHS Foundation Trust, Sherwood Forest Hospitals NHS Foundation Trust, Skills, Social Care, Staffing, State of Care Report, State of Health Care and Adult Social Care in England 2014/15, Tameside Hospital NHS Foundation Trust, Temporary Staff, The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust, Transparency, Transparency and Accountability, Trusts in Special Measures, Unacceptable Variations, Unannounced Hospital Inspections, United Lincolnshire Hospitals NHS Trust, University Hospitals of Morecambe Bay NHS Foundation Trust, Unwarranted Variations, Variations in Care, Variations in Quality of Care, Well-Led, Well-Led (CQC Inspection Question), Well-Led Indicators (CQC), Wye Valley NHS Trust
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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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Government Consultation on Francis Freedom to Speak Up Report (Department of Health)
Summary The Government has launched a public consultation to assess recommendations from the Francis Freedom to Speak Up review, to support NHS staff in speaking up about poor care and patient safety. This open consultation allows staff, patients and the … Continue reading →
Posted in Acute Hospitals, Community Care, Department of Health, End of Life Care, For Carers (mostly), For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), For Social Workers (mostly), In the News, Local Interest, Management of Condition, National, NHS, Person-Centred Care, Quick Insights, Standards, UK, Universal Interest
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Tagged Accountability, Adversarial and Defensive Culture, Avoidable Harm, Behaviours to Enable Whistleblowing, Better Handling of Cases, Bureaucracy, Confidentiality Clauses, Continuous Improvement, Coordinated Regulatory Action, CQC Recognition of Well-Led Organisations, Culture Change, Culture Change in Health and Care, Culture Change in the NHS, Culture Change in the NHS: Lessons of Two Francis Inquiries, Culture Free From Bullying, Culture of Raising Concerns, Culture of Reflective Practice, Culture of Safety, Culture of Valuing Staff, Culture of Visible Leadership, Department of Health Consultations Coordinator, Department of Health's Professional Standards Team, Department of Health's Strategy and External Relations Directorate, Duty of Candour (DoC), End-User Experience, Extending Legal Protection, External Review, Fit and Proper Person Test, Fit and Proper Person’s Test, Fit and Proper Persons Requirement for Directors, FPPT: Fit and Proper Person Test, Francis Freedom to Speak Up Report, Freedom and Responsibility to Speak Up (Francis Review Whistleblowing), Freedom of Information Act 2000 (FOIA), Freedom to Speak Up Guardian, Freedom to Speak Up Guardians, Freedom to Speak Up Report, Freedom to Speak Up Report: Principle 10: Training, Freedom to Speak Up Report: Principle 11: Support, Freedom to Speak Up Report: Principle 12: Support to Find Alternative Employment in the NHS, Freedom to Speak Up Report: Principle 13: Transparency, Freedom to Speak Up Report: Principle 14: Accountability, Freedom to Speak Up Report: Principle 15: External Review, Freedom to Speak Up Report: Principle 16: Coordinated Regulatory Action, Freedom to Speak Up Report: Principle 17: Recognition of Organisations, Freedom to Speak Up Report: Principle 18: Students and Trainees, Freedom to Speak Up Report: Principle 19: Primary Care, Freedom to Speak Up Report: Principle 1: Culture of Safety, Freedom to Speak Up Report: Principle 20: Legal Protection, Freedom to Speak Up Report: Principle 2: Culture of Raising Concerns, Freedom to Speak Up Report: Principle 3: Culture Free From Bullying, Freedom to Speak Up Report: Principle 4: Culture of Visible Leadership, Freedom to Speak Up Report: Principle 5: Culture of Valuing Staff, Freedom to Speak Up Report: Principle 6: Culture of Reflective Practice, Freedom to Speak Up Report: Principle 7: Raising and Reporting Concerns, Freedom to Speak Up Report: Principle 8: Investigations, Freedom to Speak Up Report: Principle 9: Mediation and Dispute Resolution, Freedom To Speak Up Review (Sir Robert Francis QC), Freedom to Speak Up? (Whistleblowing Review), Healthcare Governance Systems, History of Raising Concerns: a Positive Characteristic in Potential Employees, Honesty, Implications of the Francis Inquiry Report, Incident Reporting, Independent National Officer, Independent National Officer (INO), Independent National Whistleblowing Officer, Independent Patient Safety Champion, Independent Staff Concerns Advocate, Inspections and Bureaucracy, Investigations, Leadership for Culture Change, Legal Protection, Lives Ruined by Poor Handling of Staff Raising Concerns, Local Risk Management Systems (LRMS), Maintaining High Professional Standards (MHPS), Measures to Support Good Practice, Mediation and Dispute Resolution, Mid Staffordshire NHS Foundation Trust, NHS Culture, Open and Honest Incident Reporting, Open Culture, Openness, Oversight and Monitoring, Parliamentary and Health Services Ombudsman, Patient Experience, Patient Safety, PIDA: Public Interest Disclosure Act, Professional Regulators and Complaints, Professional Standards, Programme to Identify Whistleblowers Who Have Suffered Detriment, Protected Disclosure, Public Concern at Work, Public Concern at Work (PCaW), Public Interest Disclosure Act 1998 (PIDA), Quality Accounts, Quality Governance, Quality Improvement, Raising and Reporting Concerns, Raising Concerns, Reduction in Bureaucracy, Reflective Practice, Regulation, Repercussions From the Francis Inquiry Report, Reporting Culture, Reporting Culture in the NHS, Rt Hon Jeremy Hunt MP: Former Secretary of State for Health, Secretary of State for Health, Service User Experience, Sir Robert Francis QC, Strengthening Legislation, Structures to Enable Whistleblowing, Students and Trainees, Support to Find Alternative Employment in the NHS, Suspensions and Special Leave, System Regulators: Financial and Quality Regulators of NHS Services, Systems to Support Whistleblowing, Training, Training Bodies, Transparency, Vulnerable Groups, Well-Led (CQC Inspection Question), Well-Led Indicators (CQC), Whistleblowing, Whistleblowing in the NHS
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More on the NHS Culture of Openness: Lessons From Two Francis Inquiries (Department of Health)
Summary The Government has published a report explaining progress in the NHS since the Francis Inquiry report (February 2013) . It supports the full adoption, in principle, of Freedom to Speak Up review recommendations to protect whistleblowers who raise legitimate … Continue reading →
Posted in Acute Hospitals, Commissioning, Community Care, CQC: Care Quality Commission, 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, Local Interest, Management of Condition, National, NHS, Patient Care Pathway, Person-Centred Care, Practical Advice, Quick Insights, Standards, UK, Universal Interest
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Tagged Acute Care, Acute Hospitals, Assessing Risk of Harm (Not Just Past Harm), Avoidable Harm, BBC Health News, Behaviours to Enable Whistleblowing, Berwick Review, Berwick Review of Patient Safety, Better Care for Older Patients With Dementia, Building Capability, Candour, Care Certificate, Cavendish Review, Centrally-Driven Proposals, Challenges of Reconfiguration, Character Assassination of Whistleblowers, Closed Ranks Culture (Mid Staffordshire Public Inquiry), Clwyd and Hart Review Into Hospital Complaints, Code of Conduct for Healthcare Support Workers, Commonwealth Fund, Compassion in Practice, Compassionate Care, Configuration of Services, Consequences of the Francis Inquiry Report, Culture Change, Culture Change in the NHS, Culture Change in the NHS: Lessons of Two Francis Inquiries, Culture of Compassionate Care, Dementia Care in Acute General Hospitals, Dementia Care in Acute Settings, Dementia Care in General Hospitals, Dementia Care in Hospitals, Duty of Candour, EU Council’s Recommendations on Patient Safety and Health Care Associated Infections, Fit and Proper Persons Requirement for Directors, Francis Effect, Francis Inquiry, Francis Inquiry Report, Francis Report, Francis Report: Part of a Linked Set of Reports on Quality, Freedom and Responsibility to Speak Up (Francis Review Whistleblowing), Freedom to Speak Up Guardians, Freedom To Speak Up Review (Sir Robert Francis QC), Freedom to Speak Up? (Whistleblowing Review), Fundamental Standards, General Hospitals, General Medical Council (GMC), Government Response to Francis Inquiry Report, Harassment of Whistleblowers, Hard Truths, Health Education England Commission on Education and Training for Patient Safety, Health Education for Safety, Helene Donnelly OBE: Ambassador for Cultural Change at Staffordshire and Stoke on Trent Partnership NHS Trust, Honesty, Honesty and Transparency, Implications of the Francis Inquiry Report, Incident Reporting, Initiatives and Reviews into Quality of Hospital Care 2012/13, James Titcombe: National Advisor on Patient Safety and Culture & Quality at Care Quality Commission, Jane Cummings: Chief Nursing Officer for England, Keogh Mortality Review, Listening to Patients, Listening to Staff, Local Patient Safety Collaboratives, Medical Schools Council, Mid Staffordshire NHS Foundation Trust, Mid Staffordshire NHS Foundation Trust Inquiry, Mid Staffordshire NHS Foundation Trust Public Inquiry, Mistreatment of Whistleblowers, MyNHS Website: Comparing Safety Data, National Patient Safety Alerting System (NPSAS), NHS Culture, NHS England National Patient Safety Alerting System, NHS Leadership Academy’s Executive Fast Track Programme, NHS Litigation Authority, NHS Managerial Self-Interest, NHS Reform, NHS Safe Staffing, NHS Trust Development Authority, NHS Trusts and Foundation Trusts in Special Measures: 18 Months On, Nurse Staffing Levels, Nursing and Midwifery Council (NMC), Nursing Standards, Open and Honest Incident Reporting, Open Culture, Openness, Openness and Transparency, Outcome Metrics, Overbearing NHS Managerial Style, Patient Safety, Patient Safety Collaboratives Programme, Patient Safety Improvement, Patient-Centred Leadership, Patients First and Foremost, Person-Centred Model of Care for Patients with Dementia, Preventing Poor Care, Professor Don Berwick, Professor Sir Mike Richards: Former Chief Inspector of Hospitals (CQC), Professor Sir Norman Williams: President of Royal College of Surgeons, Professor Steve Field: Former Chief Inspector of General Practice (CQC), Public Interest Disclosure (Prescribed Persons), Putting Patients First, Quality Improvement, Quality Standards, Quality: Above Money, Raising Concerns, Reactions to the Francis Inquiry Report, Reconfiguration of Emergency Care System, Repercussions From the Francis Inquiry Report, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Reporting Culture, Reporting Culture in the NHS, Review of NHS Complaints System, Safe Staffing, SAFE: Safety Action for England, Safety Action for England Team (SAFE), Safety and Quality Standards, Safety Metrics, Safety Surveillance, Salford Royal NHS Foundation Trust, Serious Incident Framework, Sign Up to Safety Campaign, Sir David Dalton: Chief Executive of Salford Royal NHS Foundation Trust, Sir Robert Francis QC, Speaking Up Charter, Special Measures, Staff Whistleblowing Rights, Staffing, Standards of Care, State of Care 2013/14 (CQC), Structures to Enable Whistleblowing, Surgical Never Events Task Force Reference Group, Systems to Support Whistleblowing, Technology Enhanced Learning, Transparency, Ward Staffing Levels, Whistleblowing, Whistleblowing Helpline, Whistleblowing in the NHS
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Whistleblowing in the NHS: Light at the End of the Tunnel? (BBC News / NHS England)
Summary The review of NHS reporting culture led by Sir Robert Francis QC, which has been working achieve better protection of NHS whistleblowers who raise concerns, will report later today. The “Freedom and Responsibility to Speak Up” review was expected … Continue reading →
Posted in Acute Hospitals, BBC News, 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, Local Interest, National, NHS, NHS Employers, NHS England, Quick Insights, Standards, UK, Universal Interest
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Tagged ACAS: Advisory Conciliation and Arbitration Service (UK), Accountability, Adversarial and Defensive Culture, Alternative Dispute Resolutions (ADRs), Avoidable Harm, BBC Health News, Behaviours to Enable Whistleblowing, Black and Minority Ethnic (BME), Black and Minority Ethnic (BME) Groups, Blacklisting, Blacklisting and Kangaroo Courts, Character Assassination of Whistleblowers, Closed Ranks Culture (Mid Staffordshire Public Inquiry), Compromise Agreements, Confidentiality Clauses, Continuous Improvement, Coordinated Regulatory Action, CQC Recognition of Well-Led Organisations, Culture Change, Culture Free From Bullying, Culture of Raising Concerns, Culture of Reflective Practice, Culture of Safety, Culture of Valuing Staff, Culture of Visible Leadership, Defensive Leadership, Duty of Candour (DoC), Eight Step Model (Acronym: EVIDENCE) for Raising and Escalating Concerns: Escal8, Employment Rights Act 1996 (ERA), Enterprise and Regulatory Reform Act 2013, Escal8: Model for Raising and Escalating Concerns, EVIDENCE: Mnemonic for Escal8 - Eight Step Model for Raising and Escalating Concerns, Extending Legal Protection, External Review, FPPT: Fit and Proper Person Test, Francis Freedom to Speak Up Report, Freedom and Responsibility to Speak Up (Francis Review Whistleblowing), Freedom to Speak Up Guardians, Freedom to Speak Up Report, Freedom to Speak Up Report: Principle 10: Training, Freedom to Speak Up Report: Principle 11: Support, Freedom to Speak Up Report: Principle 12: Support to Find Alternative Employment in the NHS, Freedom to Speak Up Report: Principle 13: Transparency, Freedom to Speak Up Report: Principle 14: Accountability, Freedom to Speak Up Report: Principle 15: External Review, Freedom to Speak Up Report: Principle 16: Coordinated Regulatory Action, Freedom to Speak Up Report: Principle 17: Recognition of Organisations, Freedom to Speak Up Report: Principle 18: Students and Trainees, Freedom to Speak Up Report: Principle 19: Primary Care, Freedom to Speak Up Report: Principle 1: Culture of Safety, Freedom to Speak Up Report: Principle 20: Legal Protection, Freedom to Speak Up Report: Principle 2: Culture of Raising Concerns, Freedom to Speak Up Report: Principle 3: Culture Free From Bullying, Freedom to Speak Up Report: Principle 4: Culture of Visible Leadership, Freedom to Speak Up Report: Principle 5: Culture of Valuing Staff, Freedom to Speak Up Report: Principle 6: Culture of Reflective Practice, Freedom to Speak Up Report: Principle 7: Raising and Reporting Concerns, Freedom to Speak Up Report: Principle 8: Investigations, Freedom to Speak Up Report: Principle 9: Mediation and Dispute Resolution, Freedom To Speak Up Review (Sir Robert Francis QC), Freedom to Speak Up? (Whistleblowing Review), Gagging Clause Culture, Good Governance, Governance, Haraldsplass Deaconess University College (Bergen: Norway), Harassment of Whistleblowers, Healthcare Governance Systems, History of Raising Concerns: a Positive Characteristic in Potential Employees, Honesty, Implications of the Francis Inquiry Report, Incident Reporting, Independent National Officer, Independent National Officer (INO), Independent National Whistleblowing Officer, Investigations, Legal Protection, Lives Ruined by Poor Handling of Staff Raising Concerns, Local Risk Management Systems (LRMS), Maintaining High Professional Standards (MHPS), Mediation and Dispute Resolution, Mid Staffordshire NHS Foundation Trust Public Inquiry, Mistreatment of Whistleblowers, Monitor, NHS Culture, NHS Managerial Self-Interest, Nursing Times, Open and Honest Incident Reporting, Open Culture, Openness, Parliamentary and Health Services Ombudsman, Patient Safety, PIDA: Public Interest Disclosure Act, Primary Care, Professional Regulators and Complaints, Programme to Identify Whistleblowers Who Have Suffered Detriment, Protected Characteristics: Age; Disability; Gender Reassignment; Marriage and Civil Partnership; Race; Religion or Belief; Sex; and Sexual Orientation, Protected Disclosure, Public Concern at Work, Public Concern at Work (PCaW), Public Interest Disclosure Act 1998 (PIDA), Quality Accounts, Quality Governance, Quality Improvement, Raising and Reporting Concerns, Raising Concerns, Reflective Practice, Repercussions From the Francis Inquiry Report, Reporting Culture, Reporting Culture in the NHS, School of Health and Social Care: University of Teesside, School of Nursing and Midwifery: Staffordshire University, Severance Payments (Gagging Clauses), Shrewsbury and Telford Hospital NHS Trust, Sir Robert Francis QC, Speaking Up Charter, Staffordshire University, Structures to Enable Whistleblowing, Students and Trainees, Support to Find Alternative Employment in the NHS, Suspensions and Special Leave, System Regulators: Financial and Quality Regulators of NHS Services, Systems to Support Whistleblowing, Training, Training Bodies, Transparency, University of Teesside, Vulnerable Groups, Well-Led (CQC Inspection Question), Well-Led Indicators (CQC), Whistleblowing, Whistleblowing in the NHS
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Fit and Proper Persons Test Regulations / Statutory Duty of Candour / Fundamental Standards (Department of Health)
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
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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
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Freedom and Responsibility to Speak Up: Francis to Review Whistleblowing in the NHS (Department of Health / NHS England)
Summary Sir Robert Francis QC is leading a review of NHS reporting culture to ensure better protection of NHS whistleblowers who speak out in the public interest. The aim of this review, called “Freedom and Responsibility to Speak Up: An … Continue reading →
Posted in Acute Hospitals, Community Care, CQC: Care Quality Commission, 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), NHS England, Quick Insights, Standards, UK, Universal Interest
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Tagged 2gether NHS Foundation Trust, Avoidable Harm, Behaviours to Enable Whistleblowing, Care Quality Commission (CQC), Central London Community Healthcare Trust, Character Assassination of Whistleblowers, Closed Ranks Culture (Mid Staffordshire Public Inquiry), Culture Change, Freedom and Responsibility to Speak Up (Francis Review Whistleblowing), Freedom To Speak Up Review (Sir Robert Francis QC), Freedom to Speak Up? (Whistleblowing Review), Frimley Park Hospital NHS Foundation Trust, Harassment of Whistleblowers, Honesty, Implications of the Francis Inquiry Report, Incident Reporting, Mid Staffordshire NHS Foundation Trust Public Inquiry, Mistreatment of Whistleblowers, National Reporting and Learning System (NRLS), NHS Culture, NHS Litigation Authority, NHS Nottingham University Hospitals, North Bristol NHS Trust, NRLS Under-Reporting, Open and Honest Care: Driving Improvement, Open and Honest Incident Reporting, Open Culture, Openness, Oxleas NHS Foundation Trust, Patient Safety, Patient Safety Alerts, Patient Safety Incidents, PIDA: Public Interest Disclosure Act, Positive Culture, Potential Under-Reporting of Patient Safety Incidents to NRLS, Potential Under-Reporting to the NRLS, Public Interest Disclosure Act 1998, Public Interest Disclosures, Raising Concerns, Repercussions From the Francis Inquiry Report, Reporting Culture, Reporting Culture in the NHS, Royal Berkshire NHS Foundation Trust, Royal United Hospital Bath NHS Trust, SAFE Team: Safety Action for England Team, Safety Reporting, Salford Royal NHS Foundation Trust (SRFT), Seven Safety Indicators (NHS Choices), Sheffield Teaching Hospitals NHS Foundation Trust, Sign up to Safety, Sign Up to Safety Campaign, Sir David Dalton: Chief Executive of Salford Royal NHS Foundation Trust, Sir Robert Francis QC, Staffordshire and Stoke Trent Partnership Trust, Structures to Enable Whistleblowing, Systems to Support Whistleblowing, Taunton and Somerset NHS Foundation Trust, Whistleblowing, Whistleblowing in the NHS
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