lzipperer
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Everything posted by lzipperer
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Content ArticleIn 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.
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Eae6646cb8f8ef0fd260868518563f68This 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
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Content ArticleThis 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.
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Content ArticleThis 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.
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Content ArticleThe 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)
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Content ArticleFootball 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.
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Content ArticleCommunication 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.
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Community PostI 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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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.
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Content ArticleWhile 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.
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Community PostAs 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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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.
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Community PostThe 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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Community PostThis 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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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.
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Content ArticleThe 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."
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Content ArticleThis 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.
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Content ArticleRoot 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.
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Content ArticleThis 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.
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Eae6646cb8f8ef0fd260868518563f68Thanks for posting this. Always worth seeing what Charles Vincent has to say! Its in my pile to read.
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Content ArticleIn 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.
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Community PostHaydn -- 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 ?
