Jump to content
 View Profile  See their activity

  • Posts

    1,216

  • Joined

  • Last visited

PatientSafetyLearning Team

PSL Moderators

 Content Type 

Everything posted by PatientSafetyLearning Team

  1. Community Post
    Hi @Catherine Evans, thank you for posing this question. Martin Langham is our topic leader for investigations, @MartinL any thoughts?
  2. Community Post
    @Ron Daniels is our topic lead on deterioration, so may have some useful insight on this too.
  3. Community Post
    Hi @Faizan I thought you may be interested in a similar post from Claire Cox... @Claire Cox are you able to comment on any of Faizan's specific points?
  4. Community Post
    @Claire Cox what are your thoughts and experience?
  5. Content Article
    In his blog, David Naylor from the leadership and organisational development team at The Kings Fund, discusses the importance of creating a culture where staff feel able to speak freely and challenge decisions to improve patient safety. 
  6. Community Post
    @HelenH what do you think?
  7. Community Post
    A question posed by a delegate at our Patient Safety Learning conference 2019: 'In a publicly funded healthcare system, what role do politicians have in setting culture and improving patient safety?' What are your thoughts?
  8. Content Article
    EAST for Health & Safety: Applying behavioural insights to make workplaces safer is a report from the Behavioural Insights Team. The EAST framework focuses on four simple principles to encourage a behaviour: make it Easy, Attractive, Social and Timely (EAST).
  9. Community Post
    A question posed by a delegate at our Patient Safety Learning Conference 2019: 'How can we change the blame culture without blaming others?' What are your thoughts?
  10. Community Post
    @Linda Kenward and @Claire Cox I'm sure you both have valuable experience and insight to offer with this one...
  11. Community Post
    A question posed by a delegate at our Patient Safety Learning Conference 2019: 'As invaluable sources of fresh intelligence, how can we encourage students/learners to become active leaders in patient safety?' What are your thoughts?
  12. Community Post
    Stephen Moss, Patient Safety Learning Trustee, suggests four practical tips to help staff keep patients safe: With your colleagues ask a random selection of patients if they have felt unsafe in the last 24 hours (you might want to select a different form of words). If the answer is yes, get under the skin of why they have felt unsafe, pool the knowledge and agree what action you are going to take, or what might need escalating to your line manager. Have a discussion with your colleagues about how you can support each other to uphold your values and professionalism when the going gets tough. Be clear about what help you might need from outside of the team, and follow it up. When looking at your Ward Assurance results, satisfy yourself that where it is possible, they are outcome orientated rather than just focusing on compliance with a process. Look for ways of 'humanising' the data i.e. use a language that identifies the impact on patients and, importantly, use language throughout that will be understood by patients and the public. Too many times I see Ward Assurance results on ward corridors, for the attention of patients and families, written in 'NHS speak' ! When measuring your compliance with the Duty of Candour, don't just look at the numbers! Find a way that also establishes how families feel about the 'quality' of the response, i.e. was it open, honest and transparent and did it give what they needed. How do you think these tips could benefit your patients or service users? Have you tried anything similar that you've found has really helped? Let us know your thoughts and please feedback if you try any of them.
  13. Content Article
    In our Blueprint for Action, we outline some of the concerns around the quality of investigations.
  14. Content Article
    A workbook published by Health and Safety Executive (HSE), for employers, unions, safety representatives and safety professionals.
  15. Content Article
    Accident investigations should consider why human failures occurred. Finding the underlying (or latent, root) causes is the key to preventing similar accidents.
  16. Content Article
    A report from the Public Administration Select Committee looking at the investigation process, how it impacts those involved and how risk can be reduced through learning.
  17. Content Article
    The purpose of the International Classification for Patient Safety (ICPS) is to enable categorisation of patient safety information using standardized sets of concepts with agreed definitions, preferred terms and the relationships between them being based on an explicit domain ontology (e.g., patient safety). The ICPS is designed to be a genuine convergence of international perceptions of the main issues related to patient safety and to facilitate the description, comparison, measurement, monitoring, analysis and interpretation of information to improve patient care. Download visual representation of the framework
  18. Content Article
    In our previous blog we shared some reflections about the recent case of Dr Gawa-Barba and the implications the case has for the promotion of a learning culture in healthcare. In light of the Gawa-Barba case, the Government set up a review to which we have submitted a paper.
  19. Content Article
    When an adverse event occurs in healthcare, the consequences can be catastrophic for patients and their families. In the aftermath of such events there are multiple needs, expectations and demands. This blog from our Patient Safety Learning website, looks at the case in which Dr Hadiza Doctor Bawa-Garba was convicted of manslaughter. 
  20. Content Article
    This report from the Parliamentary Health Service Ombudsman (PHSO) explains the findings of their research, highlights the issues they have identified and sets out the action they believe needs to be taken to improve the quality of NHS investigations.
  21. Content Article
    The Parliamentary and Health Service Ombudsman (PHSO) use clinical advice as a key source of evidence to inform their thinking in around three quarters of their health investigations. It is crucial that they commission and use clinical advice correctly. It is also important that those involved in a complaint understand and have confidence in the way it has informed decisions. To meet a commitment they made in their new strategy for 2018-21, the PHSO carried out a major review of the way they use clinical advice when they investigate NHS complaints. 
  22. Content Article
    Drawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring.
  23. Content Article
    Plans for improving safety in medical care often ignore the patient's perspective. The active role of patients in their care should be recognised and encouraged. Patients have a key role to play in helping to reach an accurate diagnosis, in deciding about appropriate treatment, in choosing an experienced and safe provider, in ensuring that treatment is appropriately administered, monitored and adhered to, and in identifying adverse events and taking appropriate action.
  24. Content Article
    Researchers have shown that people often miss the occurrence of an unexpected yet salient event if they are engaged in a different task, a phenomenon known as inattentional blindness. However, demonstrations of inattentional blindness have typically involved naive observers engaged in an unfamiliar task. What about expert searchers who have spent years honing their ability to detect small abnormalities in specific types of images? We asked 24 radiologists to perform a familiar lung-nodule detection task. A gorilla, 48 times the size of the average nodule, was inserted in the last case that was presented. Eighty-three percent of the radiologists did not see the gorilla. Eye tracking revealed that the majority of those who missed the gorilla looked directly at its location. Thus, even expert searchers, operating in their domain of expertise, are vulnerable to inattentional blindness.
  25. Content Article
    This was one of Q Exhange's 2018 winning ideas. Testing the use of a tool to support domiciliary care staff in recognising the softer signs of deterioration. Improving response and communication to colleagues/health professionals (incorporating SBAR). The aim of this work is to reduce avoidable harm, enhance clinical outcomes and improve the experience of deteriorating individuals in the community.To achieve this, focus will be placed on improving recognition (softer signs and NEWS where appropriate), response and communication by domiciliary carers. 
×
×
  • Create New...