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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    Consider these actual patient experiences: A patient is admitted to the hospital for a bowel obstruction from a known malignancy. She calls her cancer specialist about this complication, but he is unavailable. A covering provider reading from her file says ‘your cancer is untreatable’. This is the first time she has heard this. A patient dies in the hospital and the next day the funeral home collects a body from the hospital morgue. After embalming the body, the funeral home is notified by the hospital that they were given the wrong body. Because of this error, it may not be possible to process the correct body in time for the wake the following day. Despite being simultaneously dreadful and familiar to healthcare professionals, cases like these are not systematically identified or addressed in hospital quality improvement programmes. As a result, we have no good way of preventing them and patients inevitably continue to suffer from these unnecessary emotional harms. The authors of this paper, published in BMJ Quality & Safety, argue these cases are examples of preventable harm that are deserving of formal capture, classification and action by the healthcare system.
  2. Content Article
    Responding to online patient feedback is considered integral to patient safety and quality improvement. However, guidance on how to respond effectively is limited, with limited attention paid to patient perceptions and reactions. The objectives of this paper, published by Health Expectations, were to identify factors considered potentially helpful in enhancing response quality; coproduce a best‐practice response framework; and quality‐appraise existing responses.
  3. Content Article
    The UKONS Telephone Triage Tool Kit outlines a clear symptom based, RAG rated ( RED, AMBER, GREEN) risk assessment process. It is used for telephone triage of patients who: have received or are receiving systemic anticancer therapy have received any other type of anticancer treatment, including radiotherapy and bone marrow graft/transplant may be suffering from disease-/treatment-related immunosuppression. The UKONS tool is evidence based and has been piloted and evaluated positively. It can be used by almost all, regardless of skill level or experience, and identifies patients at risk and advises action according to the level of risk.
  4. Content Article
    This presentation, delivered by Margaret Murphy, Lead Advisor for the World Health Organization, took place at the Patient Safety Learning conference. In this short video, Margaret argues that the hear of the matter is in the patient'd and families experiences of care and how this, alongside true engagement, can be used to drive improvement.
  5. Content Article
    The Patients Association welcomed our publication of ‘A Patient-Safe Future’, which provides a well-founded critique of the shortcomings in safety in our NHS. This is their full response.
  6. Content Article
    A report by the Centre for Health Policy at Imperial College London, an academic partner to Health Education England and the Commission on Education and Training for Patient Safety. The project team studied study the innovations taking place in the four corners of our healthcare system; to listen to the voices of patients, carers, students, and NHS staff; and to absorb the experiences of local and international education experts in patient safety. Their findings suggest that effective education and training for patient safety is realised through efforts on two equally important fronts: designing curricula and training interventions based on what we know to work, and shaping a culture which supports safe learning and care.
  7. Content Article
    The national bestseller that offers prescriptions for an economic world turned upside down.
  8. Content Article
    This guidance (HTM 05-01) sets out the Department of Health’s policy on fire safety in the NHS in England. It includes best practice guidance on management arrangements for fire safety.
  9. Content Article
    This study, published in BMJ Open, aimed to review the empirical literature to identify the activities, time spent and engagement of hospital managers in quality of care.
  10. Content Article
    Sam Morrish, a three-year-old boy, died from sepsis on 23 December 2010. An investigation, undertaken by the Parliamentary and Health Service Ombudsmen (PSHO) in 2014, found that had Sam received appropriate care and treatment, he would have survived. Yet, previous NHS investigations failed to uncover that his death was avoidable. So the family asked PSHO to undertake a second investigation to find out why the NHS was unable to give them the answers they deserved after the tragic death of their son.
  11. Content Article
    This article is from the US-based organisation - The Joint Commission, published by Sentinel Alert Event. The Joint Commission’s Sentinel Event Database reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events – from wrong site surgery to delays in treatment.
  12. Content Article
    The aim of this article, published in Dental Update, is to inform and update the reader on NHS England patient safety initiatives applicable to dentistry, specifically the development of an example Local Safety Standards for Invasive Procedures (LocSSIPs) for wrong site extraction.
  13. Content Article
    Over the next three years the Development of the Patient Safety Incident Management System (DPSIMS) project will define and deliver the successor to the National Reporting and Learning System (NRLS) and the Strategic Executive Information System (STEIS). The NRLS is more than 13 years old and due for an upgrade, which is why we're working closely with stakeholders to create a system that will provide resources to support safety improvement and help the NHS learn when things go wrong. The new system will: meet both local and national needs in terms of accessibility to both staff and patients/carers integrate with other systems strike a balance of confidentiality and transparency support an open and honest NHS culture devoted to continuous learning and improvement of patient safety
  14. Content Article
    Civility Saves Lives are a collective voice for the importance of respect, professional courtesy and valuing each other. They aim to raise awareness of the negative impact that rudeness (incivility) can have in healthcare, so that we can understand the impact of our behaviours. Their goal is to disseminate the science of the impact of incivility in healthcare. They also strive to research and collaborate on data about the impact of incivility.
  15. Content Article
    A study showed that when doctors tell heart patients they will die if they don't change their habits, only one in seven will be able to follow through successfully. Desire and motivation aren't enough: even when it's literally a matter of life or death, the ability to change remains maddeningly elusive. Given that the status quo is so potent, how can we change ourselves and our organisations? In Immunity to Change, authors Robert Kegan and Lisa Lahey show how our individual beliefs, along with the collective mind-sets in our organisations, combine to create a natural but powerful immunity to change. By revealing how this mechanism holds us back, Kegan and Lahey give us the keys to unlock our potential and finally move forward. And by pinpointing and uprooting our own immunities to change, we can bring our organisations forward with us. This persuasive and practical book, filled with hands-on diagnostics and compelling case studies, delivers the tools you need to overcome the forces of inertia and transform your life and your work.
  16. Content Article
    A just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong. How do you respond to the people involved? What do you do to minimise the negative impact, and maximise learning? This edition of Sidney Dekker’s extremely successful Just Culture offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety reporting and honest disclosure, about retributive just culture and about the decriminalisation of human error.
  17. Content Article
    Prof. Robert Kegan questions why there is a gap between a person's real intention to change and what the person actually does. He recalls an illustration in which heart doctors advise their patients to take their medications as prescribed or they would die. The follow up research shows that only 1/7 actually go on to take their medications. The other six have just as great a desire to stay alive and yet risk death by not following their doctor's advice.
  18. Content Article
    This evidence scan provides a brief overview of some of the tools available to measure safety culture and climate in healthcare. Safety culture refers to the way patient safety is thought about and implemented within an organisation and the structures and processes in place to support this. Safety climate is a subset of broader culture and refers to staff attitudes about patient safety within the organisation. Measuring safety culture or climate is important because the culture of an organisation and the attitudes of teams have been found to influence patient safety outcomes and these measures can be used to monitor change over time. It may be easier to measure safety climate than safety culture.
  19. Content Article
    In this article, published by the British Journal of Anaesthesia, the author looks at the impact a culture of blame can have upon NHS staff, including suicide, and offers recommendations for what should change.
  20. Content Article
    The aim of this study, published by the British Dentistry Journal, was to identify and develop a candidate 'never event' list for primary care dentistry.
  21. Content Article
    This paper, published by the Scandinavian Journal, Acta Odontologica Scandinavica, assesses current patient safety incident (PSI) prevention measures and risk management practices among Finnish dentists. 
  22. Content Article
    In this powerful blog, based on her personal experience of losing a child, Joanne Hughes argues you can (and should) identify and blame the error, the 'act or omission’ for the harm, but very often it is not appropriate or fair to blame the 'person' who carried out that act. Avoidably grieving parents, she highlights, do need to know 'what' is to blame and 'why' it occurred.
  23. Content Article
    In this blog, Steven Shorrock discusses Learning Teams, small group conversations and action, and makes a case for learning in the following ways: talk about everyday work start with what’s strong, not what’s wrong find ways to cross departmental boundaries and get multiple perspectives understand first what can be done by teams.
  24. Content Article
    The NHS complaints procedure is the statutorily based mechanism for dealing with complaints about NHS care and treatment and all NHS organisations in England are required to operate the procedure. This annual collection is a count of written complaints made by (or on behalf of) patients, received between 1 April 2017 and 31 March 2018 .
  25. Content Article
    This comprehensive systematic review, produced by the General Medical Council) examined the prevalence, severity and key types of preventable patient harm.
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