Rob Behrens, the Parliamentary and Health Service Ombudsman (PHSO), gave evidence to the Times Health Commission (Sylvester, 2023a; 2023b). This was a controversial session during which the PHSO...
‘SO1: Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of health care everywhere.’ .
In terms of patient safety improvement practices and culture development, a recent report published by Healthcare Excellence Canada (Gilbert et al, 2023) provides some interesting and valuable...
When we use concepts such as patient empowerment, we need to be as specific as we can about what we mean and understand about the term. We don't want the words to be just seen as a convenient ‘clarion...
One issue she discusses are the professional silos and hierarchies, for example:.
In a clinical negligence case, for example, the court must carefully unpack and analyse the level of care given to determine whether there was any negligence. Lawyers discuss with clinical experts the...
‘It would be quite wrong to conclude that the NHS as an organisation is incapable of learning and improving, but the evidence suggests that learning generally takes a long time and that...
In the light of the above, is it fair to characterise NHS efforts to handle patient safety crises and develop policy and practice in the area as akin to being on a patient safety merry-go round? It is...
‘Treating over a million people a day in England, the NHS touches all of our lives. When it was founded in 1948, the NHS was the first universal health system to be available to all, free at the...
‘We contend that part of the ongoing muddle about safety cultures stems from this lack of focused attention on the nature and implications of justice in the field of patient safety.’ .
The problems with maternity and neonatal services in East Kent, as highlighted by the independent review, are a salutary reminder of the terrible patient safety issues that can occur:.
Lord Woolf 's Civil Justice Review, Access to Justice (Woolf, 1996), changed the face of civil litigation in England and Wales. The reforms brought about judicial case management. Judges became the...
This discussion raises the issue of what is primarily driving the development of an NHS patient safety culture and how these aims could be seen negatively by nurses, doctors and other stakeholders....
‘Clinical competence was substandard, with deficient skills and knowledge; working relationships were extremely poor, particularly between different staff groups, such as obstetricians,...
‘In health we focus too much on the consequences, looking backwards at what has gone wrong. We need leaders to stop harm in advance, identifying and managing the causes and the controls.’
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