The Patient Safety Commissioner (PSC) recently published a consultation paper on draft principles of better patient safety (PSC, 2024a). The principles will act as a guide, the PSC states, for senior...
No doubt the final Dash report on the CQC will also find that the NHS health regulatory, governance framework, patient safety system is too complex, overlapping, fragmented and ripe for reform. This...
‘I'm extremely anxious about maternity services. And what frightens me is the issues we've seen raised in relation to Nottingham and Kent – I think [they] are a risk factor right across the NHS, and...
It will be impossible for any nurse or doctor to analyse everything that is relevant to their clinical practice area. They do, however, owe patients a legal duty of care and part of this will be the...
A fundamental question I also ask when considering election manifestos is how much control governments have over NHS patient safety culture development. Governments come and go, as do patient safety...
The progress report from WHO offers important insights into strategies adopted, trends, issues, challenges, opportunities and so on. This will be a key resource for all stakeholders in patient safety...
Many organisations have mission, vision or value statements and drafting them is an art. There is a service industry devoted to this:.
In the legal literature the subject of rights is a hotly debated one. Many legal theorists in a subject area called jurisprudence and elsewhere have debated the matter. It is a useful exercise to look...
An independent expert panel commissioned by the House of Commons Health and Social Care Committee (HSCC) has issued the report of its findings on the Government's progress on meeting patient safety...
Patient Safety Learning (2024) is a charity for improving patient safety that provides excellent resources to share learning. It has recently produced a report analysing the results of questions...
In his Broken Trust report from June 2023, the PHSO reviewed the most serious NHS complaints received by his office where avoidable death has resulted. The review highlighted an implementation gap,...
The call for Martha's Rule arose out of the tragic death of 13-year-old Martha Mills, who died from sepsis in 2021 at King's College Hospital, London. There was a failure to recognise that she...
‘Patients struggle to navigate the complaints system and it may take some time to find the correct organisation to complain to.’ .
‘… costs … have continued to grow at an eye-watering rate. Ten years ago, the NHS paid £900 million in damages; last year it was £2.17 billion – equivalent to the annual running costs of the biggest...
Improvement recommendations are made after a patient safety crisis, often repeated ones, but the system does not change much or at all. Errors are repeated, lessons go unlearnt. This might seem a...
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