Tag Archives: Reporting Culture

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

Latest NHS Whistleblowing Policy (NHS Improvement)

Posted on April 21, 2016 by Dementia and Elderly Care News

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 →

More on Patient Safety Concerns (BBC News / CQC)

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

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

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 →

Government Consultation on Francis Freedom to Speak Up Report (Department of Health)

Posted on March 13, 2015 by Dementia and Elderly Care News

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 →

More on the NHS Culture of Openness: Lessons From Two Francis Inquiries (Department of Health)

Posted on February 13, 2015 by Dementia and Elderly Care News

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 | 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 | Leave a comment

Whistleblowing in the NHS: Light at the End of the Tunnel? (BBC News / NHS England)

Posted on February 11, 2015 by Dementia and Elderly Care News

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 →

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

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

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

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

Freedom and Responsibility to Speak Up: Francis to Review Whistleblowing in the NHS (Department of Health / NHS England)

Posted on June 28, 2014 by Dementia and Elderly Care News

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 →

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