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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    This study, published in Risk Management and Healthcare Policy, analyses staffs perception of a safety culture and their knowledge of safety measures in the hospitals of Saudi Arabia.
  2. Content Article
    In this data briefing, John Appleby looks at nursing workforce figures and questions if the NHS can balance flexibility with demand.
  3. Community Post
    Below is another link to an incivility resource and also a fact sheet that highlights some of the issues incivility can cause and how these can impact patients. Civility Saves Lives – the impact and importance of civility in the workplace
  4. Community Post
    Here are some resources we have on the hub now that look at workplace incivility and the impact that rudeness can have on patient safety. This includes a really interesting TEDx talk from Chris Turner who founded Civility Saves Lives. TEDx: When rudeness in teams turns deadly (Chris Turner) The impact of rudeness on medical team performance: a randomised trial Make or break: incivility in the workplace BMJ Quality & Safety: Exposure to incivility hinders clinical performance in a simulated operative crisis And a news article from Nursing Notes: Nurses need to be kinder to each other or patients will be negatively affected, warns Senior Nurse
  5. Content Article
    This document sets out Barts Health Local Safety Standards for Invasive Procedures (LocSSIPs) based on the National National Safety Standards for Invasive Procedures (NatSSIPs). It includes eight sequential steps that are reinforced with clear organisational standards. These standards are a minimum, based on national best practice, to improve safety. They apply to all staff and all services that perform invasive procedures at Barts Health NHS Trust.
  6. Content Article
    Weaving together narratives from medicine, psychology, philosophy, and human performance, the book Still Not Safe looks at the patient safety movement and the state of the American healthcare system.
  7. Content Article
    Published on the Johns Hopkins University website, this commentary from Saralyn Cruickshank focuses on the newly released book Still Not Safe: Patient Safety and the Middle-Managing of American Medicine. Written by Robert Wears and Kathleen Sutcliffe, the book argues that the patient safety movement has evolved but not, in all cases, for the better.
  8. Content Article
    In his blog for Aish.com, Rabbi Efrem Goldberg talks about the power of a sincere apology and how this can be translated into medical care settings.
  9. Content Article
    Reducing the burden of harm and instilling better practice requires both systems thinking and committed local ownership. Comparisons of health systems across the world can help visualise best practice, opportunities for learning and potential for diffusion of innovations. Most importantly, depicting the global state of patient safety showcases exemplar safety systems and facilitates exploration of their characteristics and enablers.   This report seeks to stimulate ambitious visions and bold action to significantly reduce harm and improve the lives of millions of patients and their families. 
  10. Content Article
    Health and well-being boards (HWBs) were established under the Health and Social Care Act 2012 to act as a forum in which key leaders from the local health and care system could work together to improve the health and well-being of their local population. In this report from the Kings Fund, Richard Humphries examines the part HWBs and local government more broadly, have played in the emergence of Integrated Care Systens (ICSs) so far and options for their future.  Significantly, this report does not mention patient safety. Neither does it reflect on improvement in safety and quality though the more effective cross organisational collaboration at local system level.
  11. Content Article
    Communication failures in healthcare teams are associated with medical errors and negative health outcomes. These findings have increased emphasis on training future health professionals to work effectively within teams. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) communication training model, widely employed to train healthcare teams, has been less commonly used to train student interprofessional teams. This study, published in BMJ Quality and Safety, reports the effectiveness of a simulation-based interprofessional TeamSTEPPS training in impacting student attitudes, knowledge and skills around interprofessional communication.
  12. Content Article
    This study, published in US journal Chest, looks at the case of a patient who experienced severe hypoglycemia due to an infusion of a higher-than-ordered insulin dose. The event could have been prevented if the insulin syringe pump was checked during the nursing shift handoff. Risk management exploration included direct observations of nursing shift handoffs, which highlighted common deficiencies in the process. This led to the development and implementation of a handoff protocol and the incorporation of handoff training into a simulation-based teamwork and communication workshop.
  13. Content Article
    Regardless of a patient's health literacy level, it is important that staff ensure that patients understand the information they have been given. The teach-back method is a way of checking understanding by asking patients to state in their own words what they need to know or do about their health. It is a way for clinicians to confirm they have explained things in a manner their patients understand. The related show-me method allows staff to confirm that patients are able to follow specific instructions (e.g., how to use an inhaler).
  14. Content Article
    This American article looks at a patient safety communication strategy called 'teach-back', outlined by a Agency for Healthcare Research and Quality (AHRQ) guide. During patient teach-back, providers explain patient medical conditions, treatment options, or self-care instructions to patients. They then ask patients to repeat the information back to them in their own words. The goal of teach-back is to ensure that you have explained medical information clearly so that patients and their families understand what you communicated to them,” the AHRQ guide explains. “This low-cost, low-technology intervention can be the gateway to better communication, better understanding, and ultimately shared decision-making.”
  15. Content Article
    Health professionals often assume they are skilled at communicating with colleagues, patients and families. However, many patient safety incidents, complaints and negligence claims involve poor communication between healthcare staff or between staff and patients or their relatives, which suggests staff may overestimate how effectively they communicate. Teams that work well together and communicate effectively perform better and provide safer care. There is also growing evidence that team training for healthcare staff may save lives (Hughes et al, 2016). This article explores why teamwork and communication sometimes fail, potentially leading to errors and patients being harmed. It describes tools and techniques which, if embedded into practice, can improve team performance and patient safety.
  16. Content Article
    The communication between nurses and patients' families impacts patient well-being as well as the quality and outcome of nursing care, this study aimed to demonstrate the facilitators and barriers which influence the role of communication among Iranian nurses and families member in ICU.
  17. Content Article
    This is a patient safety solution document from the World Health Organization, focusing on communication during handover. It includes suggested actions, potential barriers and also ways to engage patients and families.
  18. Content Article
    This report, published in BMJ Open Quality, sets out the findings of a National Health Service Improvement (NHSI) working group on care communication which included clinicians, patients, patient representatives, NHSI staff and academics from different disciplines. The group’s activities included running four national focus groups and discussion days, in addition to conducting national and international literature searches on healthcare communication and communication improvement.
  19. Content Article
    The Inaugural Australian Patients for Patient Safety Workshop, held over 3 days in Perth from July 7 ‐9, 2009, brought together a group of 40 health consumers, many of whom had experienced medical error or health system failure, health providers and health policy makers from around Australia.   Participants were selected for their efforts as change agents who have worked proactively to improve the safety of health care in Australia and their desire to further improve safety in health care, in partnership. Participants came together to build trust, functional working relationships grounded in mutual respect and appreciation of what each brought to the field of patient safety and to form strategies and action plans for improving patient safety in Australia. The core of those strategies and action plans is the Perth Declaration for Patient Safety.
  20. Content Article
    This book explains the role of communication in mental health, emergency medicine, intensive care and a wide range of other health service and community care contexts. It emphasises the ways in which patients and clinicians communicate, and how clinicians communicate with one another. The case studies explain why and how communication is critical to good care and healing. Each chapter analyses real-life practice situations, encourages the learner to ask probing questions about these situations, and sets out the principal components and strategies of good communication. 
  21. Content Article
    The Australian Open Disclosure Framework provides a nationally consistent basis for open disclosure in Australian healthcare. The framework is designed to enable health service organisations and clinicians to communicate openly with patients when healthcare does not go to plan.
  22. Content Article
    The author of this article, published in Health Issues, argues that the experience and wisdom of consumers positively impacts on improvement in every dimension of health care quality. From a consumer perspective, those dimensions of quality can be described as care that is: accessible equitable safe effective efficient timely appropriate consumer-centred.
  23. Content Article
    This editorial piece, published in the Medical Journal of Australia (MJA), argues that new strategies need to be considered in order to make significant progress in the area of patient harm. One such approach is to enable patients, carers and families who have experienced poor-quality care and preventable health care harm to develop solutions in partnership with clinicians, health providers and policymakers.
  24. Content Article
    Published in Acta Paediatrica, the parents of a baby who was born prematurely and died, share their experiences of the communication and choices given to them before the birth.
  25. Content Article
    The Clinical Excellence Commission in New South Wales, Australia, is driving person-centred care by stimulating districts to compete to provide it. Karen Luxford and Stephanie Newell describe the integrated approach, its uptake, and encouraging early evidence of change.
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