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lzipperer

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Everything posted by lzipperer

  1. Content Article
    In 2019, the US-based National Quality Forum (NQF), is convening a new multi-stakeholder expert committee to revisit and build on the work of the Diagnostic Quality and Safety Committee. This report updates a scan done when the National Quality Framework (NQF) diagnostic measures framework first came out in 2017. The assessment of the current state of diagnostic errors measurement, themes that have emerged since the earlier document and new measures that have been published may be of interest to researchers in the UK doing work in this important segment of patient safety work.
  2. Article Comment
    Nice related freely-available study: Safety concerns with consumer-facing mobile health applications and their consequences: a scoping review. Saba Akbar, Enrico Coiera,, Farah Magrabi. Journal of the American Medical Informatics Association. https://doi.org/10.1093/jamia/ocz175
  3. Community Post
    Thanks Clive -- Chris Collison is another "go to" resource for this type of info.
  4. Community Post
    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 ?
  5. Community Post
    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?
  6. 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.
  7. Content Article
    "Looking back down the path of another person’s journey is not the same thing as making the trip yourself." What a great quote! It is so true. Henriksen and Kaplan discuss hindsight bias, outcome knowledge and adaptive learning in this paper published in BMJ Quality & Safety in 2003.
  8. Content Article
    Helen Haskell, co-chair of the WHO Patients for Patient Safety Advisory Group, brings the patient leader perspective to her take on World Patient Safety Day in this essay published in the BMJ.
  9. Content Article Comment
    Jules -- thanks for sharing this. I have heard from colleagues that systematic reviews aren't always that useful in day-to-day practice. How would you suggest they use this material to further their efforts on the front line to generate the use of simulation?
  10. Content Article
    I’d like to introduce my ‘Letter from America’, 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.
  11. Content Article Comment
    Judy -- you have nicely summarized how AARs serve as a source of knowledge sharing to help organizations learn--but I am not sure how they are optimized to do that in a real "human-centered" rather than "information sharing" way. Just developing and disseminating a report is a good thing, but the tacit knowledge that makes the AARs potentially so powerful as learning opportunities can get lost when the discussions are translated to an explicit object. How has your experience made AARs into a true knowledge transfer strategy throughout an organization?
  12. Community Post
    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!
  13. Community Post
    Here is a good freely-available study on speaking up: https://www.pslhub.org/learn/culture/a-qualitative-study-of-speaking-out-about-patient-safety-concerns-in-intensive-care-units-r405/
  14. Community Post
    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
  15. Community Post
    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
  16. Community Post
    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)? Emerging safety issues in artificial intelligence
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