lzipperer
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I suggest the US-based Institute for Safe Medication Practices (ISMP) newsletters: https://www.ismp.org/newsletters The flagship publication for the acute care environment makes its featured articles available for free.
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I do see some value in having a specialist with the right training as a hub to span boundaries and apply the safety sciences to the work of envisioning, designing and implementing safety strategies. See this white paper by the American Institute for Safe Medication Practices on the value of a medication safety officer...some similar arguments could be made here to support the UK strategy.
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What do hub members think about use of the term "near miss" vs "close call" vs "good catch" to describe errors that are caught before the reach or harm the patient? If you have a favorite, can you say why?
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As just a conceptual observer of RCAs, these reads by US authors immediately came to mind when I saw this thread. These authors have tried to examine the RCA process or build out the model to make it more effective. I will add the resources to the hub area referred to above but list them here now due to keep them close at hand for the conversation:
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient Safety Foundation; 2015.
Hagley G, Mills PD, Watts BV, Wu AW. Review of alternatives to root cause analysis: developing a robust system for incident report analysis. BMJ Open Qual. 2019 Aug 1;8(3):e000646. This review is likely to be on point as it lists tools identified by a literature review that sought to highlight RCA incident review alternatives to RCAs.
Two PSNet articles that provide background :
Root Cause Analysis Gone Wrong: 2018
Rethinking Root Cause Analysis: 2016
I hope these are helpful in feeding the "fire"!
Lorri
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"There is an aspect of information exchange that has attracted less attention and fewer resources: that patients are experts in their experience and know much more than clinicians about their own health and the needs and goals important to them." From: https://catalyst.nejm.org/information-asymmetry-untapped-patient/
Such an important point to see patients as knowledge hubs on their own care experiences.
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The US-based Leapfrog Group is a nonprofit organisation that routinely gauges hospital performance to inform purchaser choices as they navigate the healthcare system. While there are discussions on the value of the ratings ... they still pack a punch for organizations who do or don't do well. The latest set of numbers are out: Megan Brooks. One Third of US Acute-Care Hospitals Get 'A' on Patient Safety: Survey - Medscape - Nov 07, 2019.
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This is such an important question .. I am looking forward to the responses. I see it as a distinct leadership quality to effectively recognize employees/peers that are brave enough to raise the red flag when they feel uncomfortable about something they have seen or heard. Heck -- its hard enough to speak up some times ... even when people know they should. See this insight from the IHI on that topic:
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Thanks Clive -- Chris Collison is another "go to" resource for this type of info.
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Haydn -- I applaud you for trying to define "lessons learned." Its a tough one -- like so many other terms in the knowledge management realm. But defining what it is you are trying to track and develop systems to optimize is so important. Working with peers in your organization to build a shared mental model around use of terms will help to collectively build understanding and buy-in around what you aim to accomplish.
These sources may help:
Nick Milton is a leader in the KM field and this survey may give you some examples of language that could work: https://www.knoco.com/Knoco White Paper - Lessons Learned survey.pdf
His handbook builds on these ideas with some practical instruction on moving forward with a lessons learned initiative: https://www.sciencedirect.com/book/9781843345879/the-lessons-learned-handbook
another resource : NATO Lessons Learned Handbook: https://nllp.jallc.nato.int/iks/sharing public/nato_ll_handbook_2nd_ed_final_web.pdf
Good luck in wrestling this one to the ground ?
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Hi Jules - - great of you to try and focus this section of the community. Do you think its necessary or important here to define what we mean by leadership? Are we discussing "executives and decision makers" per se or any individual that embodies what leadership is about?
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Root case analysis has its detractors but can still bring value to understanding deep-seated problems that affect the safety of care.
Does anyone have a checklist of elements of an effective TRAINING strategy to bring staff on board with the process? Not how to do an RCA, but to bring a team to the skill competencies they need to do RCA?
I'd appreciate hearing your experiences. Please tell your tales!
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Here is a good freely-available study on speaking up:
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I think this is an unexplored area that affects "blunt end staff" -- a lot. Granted, they aren't "laying of hands" and their burnout and bullying may not as directly affect clinical safety, but it does signify the lack of a safety culture. If we profess to fix the entire culture to enable safety--health care needs to see the negative impacts on non-clinical staff both in clinical and non-clinical environments as well.
This is another good one: https://doi.org/10.1016/j.jsr.2017.12.015
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I think its also important to think about how the "toxic environment" burn the people out who end up trying to manage it--on both the sharp and the blunt end. This 1999 article from the Harvard Business Review is one of my favs on that topic: https://www.ncbi.nlm.nih.gov/pubmed/10539211 The full text should be free with registration https://hbr.org/1999/07/the-toxic-handler-organizational-hero-and-casualty
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Artificial Intelligence is creating a lot of buzz in the US and around the world.
This perspective from the US site AHRQ Patient Safety Net explores a range of issues that could affect the uptake artificial intelligence systems in health care. What do hub members think? Are we destined to encounter Hal (from 2001: a Space Odyssey) or Samantha (from Her)?
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Welcome - AI - The challenge of adopting safe solutions
in Artificial Intelligence
Posted
I think its important to consider how biases (research, implicit etc) can affect the success of AI. both in the results and how it is interpreted.