Speaking up ad whistleblowing

Question 1

Why has the quality and saftey of care risen?

Answer 1

Due to:
Examples of the harm that ca arise from poor care

Increasing knowledge of the different quality of care recieved by patients in different places.

Acknowledgement of the financial cost of poor care

Government policies seeking to address these problems.

Question 2

Why might it be difficult to report something?

Answer 2

Loss of situational awareness / tunnel vision

Authority gradients

Too much deference / confidence

Question 3

What is the WHO checklist?

Answer 3

World Health Organisation’s surgical checklist includes items designed to encourage good communication.

Focuses oth relationships withi the team ad ensuring clear shared understanding of operatio ad risk

Associated with improved saftey a lower mortality.

Question 4

What measures have been put in place after the freedom to speak up review?

Answer 4

Statutory Duty of Candour

Freedom to Speak Up Guardians

Question 5

What is the duty of candour?

Answer 5

If patients experience moderate or severe harm in the course of their care, they or their relatives should be informed.

This is a legal responsibility.

Question 6

What is a freedom to speak up guardian?

Answer 6

Employed in each NHS organisation to provide a point of contact, advice and an alternative means of raising concerns.

CQC initiative to encourage speaking up about issues before they become larger problems.

Question 7

What things should you do specifically as part of your duty of candour?

Answer 7

Own up to your mistake made

Face to face discussion about what happened and why

A discussion about any further actions needed because of the mistake

A written report on what happened

An apology - important!

Question 8

Who speaks up?

Answer 8

Most concerns are raised by nurses.
32% = issues of patient safety and quality
45% = bullying and harassment
Since the guardian initiative has been implemented, here has been a significant rise in speaking up.

Question 9

What are the barriers to speaking up?

Answer 9

Hierarchical relationships

No certainty it will lead to improvements

Can provoke informal hostility or reduce quality of working relationships

Difficult to be sure if something is really a problem.