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lzipperer

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Everything posted by lzipperer

  1. Content Article
    In this Institute for Healthcare Improvement blog, Derek Feeley discusses how "joy at work" during times of collective stress can nurture a sense of purpose and community that supports staff well-being and reduces burnout. 
  2. Content Article Comment
    This post reminded me of John Nance's book "Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care". Worth a read in its entirely -- but here is a nice excerpt. https://abcnews.go.com/GMA/Books/story?id=7319785&page=1
  3. Content Article
    This guide, published by the American-based Agency for Healthcare Research and Quality (AHRQ) looks at how patient safety can be improved in primary care settings by engaging patients and families. It is the result of a two-year effort to develop an evidence-based collection of interventions and case studies exploring how primary care organisations and practitioners engage patients and families in improvement work and in their personal safe care. The resource includes a user's guide and is accompanied by a deep environmental scan that informed the development of the work.
  4. Content Article
    This month’s Letter from America highlights approaches to addressing persistent patient safety challenges, such as overprescribing of opioids and staff burnout, through working with clinicians, staff and patients to enhance service delivery and care and opportunities to effectively engage communities. Letter from America is the latest in a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States.
  5. Content Article
    The Communication and Optimal Resolution (CANDOR) process is an evidence-based approach developed through support and testing by the US Agency for Healthcare Quality and Research. The CANDOR program aids healthcare institutions and practitioners to effectively respond when accidental, unexpected harm befalls patients in their care. The CANDOR toolkit contains information to help organisations implement the program. It covers topics such as event reporting and analysis, disclosure response and organisational learning. Further reading - The 'seven pillars' response to patient safety incidents: effects on medical liability processes and outcomes (December 2016)
  6. Content Article
    The US-based Planetree organisation has long been a leader in establishing processes and mindsets that enable safe, patient-centred care. This resource collection includes a variety of tools, templates and instructions that help organisations and teams embed effective communication behaviours and activities into their daily work. Resources focus on tactics such bedside rounding, huddles, patient and family engagement council formation and physician interaction coaching.
  7. Content Article
    Football is a popular American pastime. Its focus on collaboration, individual skill reliance and teamwork serves as a touchpoint for the January 2020 Letter from America. Letter from America is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. 
  8. Content Article
    Communication and care delivery is enhanced when teams work together well. TeamSTEPPS® is a US government set of teamwork tactics and tools designed to help health care professionals work together safely and effectively.
  9. Article Comment
    Is there an official analysis available looking at these incidents?
  10. Community Post
    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.
  11. Community Post
    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?
  12. Content Article
    'Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series covers successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery.
  13. Content Article
    While a recognised and accepted investigation process, barriers exist to the effective use of root cause analysis and implementation of improvements identified to generate sustainable action. This article lists tools identified by a literature review that sought to highlight incident review alternatives to RCAs, with particular focus on low-harm or no-harm events that should be examined to minimise their potential for contributing to patient harm.
  14. Community Post
    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
  15. Content Article Comment
    Thank you to the reporter for sharing this story. I am saddened that 20 years after To Err is Human and subsequently An Organisation with a Memory this sort of response still occurs. I am troubled by the leadership failure here!
  16. Community Post
    "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.
  17. Community Post
    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.
  18. Community Post
    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:
  19. Article Comment
    Retained foreign objects are a persistent challenge in the US too. Accreditation giant the Joint Commission in Illinois has stats drawn from voluntarily submitted reports that indicate their hospitals struggle with the problem too.
  20. Content Article
    ‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery.
  21. Content Article
    The debate around the presence of medical error in healthcare today still solicits debate. While it is agreed that one death due to medical error is too many, Mazer and Nabhan in this perspective discuss the intense interest by the media and others in numbers that are shared – whether they are accurate or not. They suggest instead that the focus of discussion and interest should not be solely on how many... but the "why."
  22. Content Article
    This perspective from the US discusses problems with the use of root cause analysis (RCA) in healthcare. The authors summarise research examining the process and share recommendations to enhance the use of RCAs from the National Patient Safety Foundation document RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.
  23. Content Article
    Root cause analysis (RCA) is a recognised yet problematic process for examining failures deeply. The goal of RCAs are to identify systemic problems rather than blame individuals. Effective RCAs devise strategies to improve processes that mitigate conditions that contribute to failure. The RCA2 report is the result of a multidisciplinary consensus effort lead by the US-based National Patient Safety Foundation. The document outlines techniques to enhance the RCA process and enable organisations using the highlighted approaches to improve RCA efforts to more reliably impact improvement.
  24. Content Article
    This commentary, published in the Journal of the American Medical Informatics Association (JAMIA), highlights the value of explicit inclusion of context in Electronic Health Records (EHRs). The author highlights how discussions of why decisions were made illustrate important relationships in elements of patient care than can often get lost in clinical notes.
  25. Content Article Comment
    Thanks for posting this. Always worth seeing what Charles Vincent has to say! Its in my pile to read.
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