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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    PHSO – Labyrinth of Bureaucracy is the follow-up report to the November 2014 Patients Association report on the Parliamentary and Health Service Ombudsman, The ‘Peoples’ Ombudsman – How it Failed us.
  2. Content Article
    The Magnet Recognition Program designates organisations worldwide where nursing leaders successfully align their nursing strategic goals to improve the organisation's patient outcomes. The Magnet Recognition Program provides a road map to nursing excellence. Research has documented an association between hospitals with Magnet recognition and better outcomes for nurses and patients. However, little longitudinal evidence exists to support a causal link between Magnet recognition and outcomes. This study compares changes over time in surgical patient outcomes, nurse-reported quality, and nurse outcomes in a sample of hospitals that attained Magnet recognition between 1999 and 2007 with hospitals that remained non-Magnet.
  3. Content Article
    Several organisations, researchers and clinicians have discussed the need for a patient safety culture in dentistry. Strategies are available to help improve patient safety in healthcare and deserve further consideration in dentistry. Published by the British Dentistry Journal, this article: discusses the history of patient safety initiatives in healthcare and dentistry describes strategies that can be applied to identify patient safety issues in dentistry emphasises the importance of both process and cultural factors in developing a safer healthcare environment.
  4. Content Article
    Mike Robbins is an expert in teamwork, leadership, and emotional intelligence who delivers keynote addresses to audiences throughout the world. In this talk at TEDxBellevue, Mike talks about the power of appreciation. As Mike discusses, there is an important distinction between 'recognition' and 'appreciation'. Leaders, teams, organisations and individuals who understand this distinction can have much more impact, meaning, and productivity in their lives and with the people around them. He also discusses some important research in the field of positive psychology that exemplifies the importance of appreciation.
  5. Content Article
    This review has examined the commissioning and use of clinical advice by the Parliamentary Health Service Ombudsman’s (PHSO) service during the assessment and investigation of complaints made by (or on behalf of) recipients of NHS care. In establishing findings, conclusions, and recommendations, the author, Liam Donaldson, has asked a series of important questions, including: Does the current process for engaging clinical advice work effectively? What, if any, are the main problems, risks, and areas of dysfunction? Does the process need to be improved and if so why and how?
  6. Content Article
    Information overload can be defined as a difficulty a person can have in comprehending issue and making judgments that are caused by the presence of too much information. Information overload occurs when the amount of input to a system surpasses its processing capability. Decision-makers have a limited cognitive processing ability. Consequently, when information overload happens, it is possible that a decline in decision quality will take place. Decision-makers, such as medical consultants, have fairly limited cognitive processing capacity. Consequently, when information overload occurs, it is likely that a reduction in decision quality will occur. The aim of this study, originally published by the Journal of Biosciences and Medicines, is to assess the impact of information overload on medical consultants’ life, its causes, and potential ways to deal with it.
  7. Content Article
    In this presentation on improving patient safety and reducing alarm fatigue, the panellists discuss the right and wrong way to use continuous surveillance monitoring. 
  8. Content Article
    The US based, Stroke VTE (venous thromboembolism) Safety Recommendations provide four key steps to help prevent deep vein thrombosis (DVT) and pulmonary embolism (PE) in stroke patients.
  9. Content Article
    The Institute for Healthcare Improvement ran a National Forum CEO and Leadership Summit in December 2019. This slide pack gives an overview of the summit, including speaker presentations and key objectives of the meeting.
  10. Content Article
    When the Harvard Business Review (HBR) asked Robert Sutton for suggestions for its annual list of Breakthrough Ideas, he told them that the best business practice he knew of was 'the no asshole rule'. Sutton's piece became one of the most popular articles ever to appear in the HBR. Spurred on by the fear and despair that people expressed and the tricks they used to survive with dignity, Sutton was persuaded to write this book. He believes passionately that civilised workplaces are not a naive dream, that they do exist, do bolster performance and that widespread contempt can be erased and replaced with mutual respect when a team or organisation is managed right. There is a huge temptation by executives and those in positions of authority to overlook this trait especially when exhibited by so-called producers, but Sutton shows how overall productivity suffers when the workplace is subjected to this kind of stress.
  11. Content Article
    Typically issued in response to a new or under-recognised patient safety issue with the potential to cause death or severe harm. NHS Improvement aim to issue warning alerts as soon as possible after becoming aware of an issue and identifying that healthcare providers could take constructive action to reduce the risk of harm. Warning alerts ask healthcare providers to agree and coordinate an action plan, rather than to simply distribute the alert to frontline staff.
  12. Content Article
    Incivility chips away at people, organisations, and our economy. Slights, insensitivities, and rude behaviors can cut deeply. Moreover, incivility hijacks focus. Even if people want to perform well, they can't. Customers too are less likely to buy from a company with an employee who is perceived as rude. In this book, Christine Porath shows how people can enhance their influence and effectiveness with civility. Combining scientific research with fascinating evidence from popular culture and fields such as neuroscience, medicine, and psychology, this book reminds managers and employers what they can do right now to improve the quality of their workplaces.
  13. Content Article
    In this blog, published by Physician-Patient Alliance for Health & Safety, Drs. Nidhi Madan and Annabelle Volgman discuss why early detection of atrial fibrillation can lead to a significant reduction of morbidity and mortality.
  14. Content Article
    As healthcare organisations seek to enhance safety and quality in a changing environment, organisational learning practices can help to improve existing skills and knowledge and provide opportunities to discover better ways of working together. Leadership at executive, middle management, and local levels is needed to create a sense of shared purpose. This shared vision should help to build effective relationships, facilitate connections between action and reflection, and strengthen the desirable elements of the healthcare culture while modifying outdated assumptions, procedures, and structures.
  15. Content Article
    This article, published by Medium, looks at the story of a woman who had a stroke while pregnant. Both survived. The authors highlight a growing concern that the US is in the midst of a maternal morbidity and mortality crisis.
  16. Content Article
    This report examines the key factors at work in organisational failure and learning, a range of practical experience from other sectors and the present state of learning mechanisms in the NHS before drawing conclusions and making recommendations. It's recommendations include the creation of a new national system for reporting and analysing adverse health care events, to make sure that key lessons are identified and learned, along with other measures to support work at local level to analyse events and learn the lessons when things go wrong.
  17. Content Article
    According to the National Institutes of Health (January 2019), more than 130 people in the United States die after overdosing on opioids every day. Among these deaths are patients in the hospital setting, recovering from surgical procedures or undergoing sedation, who are often prescribed opioids such as morphine and oxycodone to manage pain – a necessity for healthy and comfortable recovery. But at certain doses, these drugs can also cause respiratory failure, and, because each patient is different, there is no one dose that is 'right' or 'wrong'. Hospitals must take action to ensure their staff are aware of these risks, and put protocols in place to prevent patient deaths. The authors of this US article, published by Medium, offer recommendations for improving patient safety in this area.
  18. Content Article
    Helen Marie Bousquet tragically passed away after what has been described by her son as 'a basic routine procedure' for knee surgery. He argues that her tragic and avoidable death highlights the need for better assessment of patients for sleep apnea and for better treatment and monitoring of these patients before, during and after surgery. The recent jury finding that a hospital nurse was negligent in the care of Helen Marie Bousquet raises the question whether negligence can result in safer patient care. In his blog, Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), looks at this case and the lessons that can be learned.
  19. Content Article
    In this article published in the British Columbia Medical Journal, Drs Richard Merchant and Matt Kurrek encourage the use of capnographic monitoring to improve the safety of patients undergoing procedural sedation.
  20. Content Article
    Since the emergence of the opioid epidemic in the United States at the beginning of the 21st century, more than 400,000 Americans have died as the result of an opioid overdose. As of 2018, the Substance Abuse and Mental Health Services Administration estimates that more two million people have an opioid use disorder. With the rate of opioid-related inpatient stays and the number of opioid-related emergency department visits continuing to rise dramatically in the US, hospitals have the opportunity to make a major impact in reducing morbidity and mortality related to opioid use. This document, produced by the Institute for Healthcare Improvement, provides system-level strategies that hospitals can implement immediately to address the challenges of preventing, identifying, and treating opioid use disorder.
  21. Community Post
    This recent report from New Zealand looks at restorative approaches and may also be of interest: A restorative justice innovation: Responding to harm from surgical mesh in New Zealand (December 2019) Thank you for sharing it on the hub @Jo Wailling
  22. Content Article
    This article looks a some of the research into clinician burnout and the importance of early intervention. Perhaps the 72% of doctors, in a study in 2018, who said that they would go to work even when unwell or not resilient enough to work safely provides the most powerful evidence of this being both an organisational and individual problem that needs immediate attention.
  23. Community Post
    Hi @Sophie E Caswell the following resources around consent may be helpful... GMC - Consent: patients and doctors making decisions together (June 2008, currently under review) Consent: The Montgomery Ruling (2015)
  24. Content Article
    Earlier this year, the World Health Organization declared 17 September the first World Patient Day and presented it as an opportunity to speak up for patient safety. A week or so beforehand, health leaders from across the world had met in Salzburg, Austria, at the request of Salzburg Global Seminar and the Institute for Healthcare Improvement (IHI) to explore ways of improving the measurement of patient safety. The Lucian Leape Institute, an initiative of the IHI, led the convening and content curation. Participants of Moving measurement into action: designing global principles for measuring patient safety agreed that there is no single measure that allows all stakeholders in all settings to assess the past, current, and future safety of their system. Participants agreed a system of measures must be carefully designed to assess the safety of patients throughout their health journey. The conversations in Salzburg have helped establish eight global principles for the measurement of patient safety. They feature in this new document, Salzburg Statement on Moving Measurement into Action: Global Principles for Measuring Patient Safety.
  25. Content Article
    In this article, Human Factors Consultant, Jayne Higgs, talks about systems thinking. She highlights the different components that contribute to systems thinking (including human factors) and argues that this approach can aid a move away from a narrow-perspective blame culture.
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