lzipperer
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Everything posted by lzipperer
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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 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.
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Content ArticleHelen 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.
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Content Article CommentJules -- 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?
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Content ArticleI’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.
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Content Article CommentJudy -- 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?
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Community PostRoot 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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Community PostHere 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/
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Community PostI 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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Community PostI 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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Community PostArtificial 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
