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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    This report describes the lack of clear roles, responsibilities and accountability for workforce planning and supply in England. In reality, this means that the health and care workforce is not growing in line with increasing population need for health and care services and there are large numbers of vacant posts throughout the system. This impacts upon patient safety and outcomes, and leads to a challenging working environment for staff. The RCN make the case for this to be resolved through legislation, alongside additional investment in the nursing workforce and a national health and care workforce strategy for England. The RCN is clear, it is no longer the time to be discussing whether legislation is needed, instead, we should also be focussed on how we go about securing these necessary changes in law.
  2. Content Article
    Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. In this series of posts, he outlines a number of myths, misunderstandings, and false equivalencies about Human Factors. 
  3. Content Article
    Good patient-pharmacist communication improves health outcomes. There is, however, room for improving pharmacists’ communication skills. These develop through complex interactions during undergraduate pharmacy education, practice-based learning and continuing professional development. The aim of the research, published in Systemic Reviews, is to understand how educational interventions develop patient-pharmacist interpersonal communication skills produce their effects.
  4. Content Article
    Patients' self‐management practices have substantial consequences on morbidity and mortality in diabetes. While the quality of patient‐physician relations has been associated with improved health outcomes and functional status, little is known about the impact of different patient‐physician interaction styles on patients' diabetes self‐management. This study, published by the US Journal of General Internal Medicine, assessed the influence of patients' evaluation of their physicians' participatory decision‐making style, rating of physician communication, and reported understanding of diabetes self‐care on their self‐reported diabetes management.
  5. Content Article
    Engaging patients and their families in quality and safety is considered central to providing truly patient-centred care. This systematic review included 48 studies involving the input of patients, family members, or caregivers on health care quality improvement initiatives to identify factors that facilitate successful engagement, patients' perceptions regarding their involvement, and patient engagement outcomes.
  6. Content Article
    Building on published patient safety research literature, this paper from the OECD, aims to broaden the existing knowledge base on safety lapses occurring in primary and ambulatory care settings.
  7. Content Article
    Published by the Canadian Patient Safety Institute, this paper describes an investigation into engaging with patients and families that have been harmed and recommends best practices for organisations to enable such collaboration.
  8. Content Article
    Clinicians who are unable to cope with their emotions after a medical error or adverse event are suffering in silence. These healthcare providers are often told to take care of the next patient without an opportunity to discuss the details of the event or share how this has affected them personally and professionally. While patients and families are the first victims of such events, we refer to the healthcare providers who are involved as the second victims.
  9. Content Article
    Involvement in an adverse event or error can have serious effects on health care workers. Spotlighting how operating room culture can deter individuals from seeking help, this commentary emphasises the importance of assisting perioperative nurses immediately after a harmful mistake.
  10. Content Article
    Published in BMJ Quality and Safety The term ‘second victim’ refers to the healthcare professional who experiences emotional distress following an adverse event. This distress has been shown to be similar to that of the patient, the ‘first victim’. The aim of this study was to investigate how healthcare professionals are affected by their involvement in adverse events with emphasis on the organisational support they need and how well the organisation meets those needs.
  11. Content Article
    Saying sorry meaningfully when things go wrong is vital for everyone involved in an incident, including the patient, their family, carers and the staff that care for them. This leaflet is part of NHS Resolution's work on duty of candour.
  12. Content Article
    The act of open disclosure of an adverse event alone may not be enough for patients or their families. Patients and patient advocates are asking for increased transparency and a greater role in the process of change. When properly handled, involving patients in post‐event analysis allows risk management professionals to further improve their organisation's systems analysis process while empowering patients to be part of the solution. First published by the US-based Journal of Health Care Risk Management, this article examines the legal and psychological considerations surrounding the involvement of patients in system failure analysis and provides tools for selecting patients who are able to benefit from this process and for adequately preparing patients and caregivers for what lies ahead.
  13. Content Article
    Objective: To determine whether patients/family members interviewed could identify at least one contributing factor for the event they experienced. Secondary objectives included understanding the way patients/family members became aware of adverse events, the types of contributing factors patients/family members identified for different types of adverse events, and recommendations provided by patients/family members to address the contributing factors. Originally published in Health Services Research.
  14. Content Article
    Objectives: To explore patients' and carers' experiences of rural general practice to identify their perceptions of safety of care. Design, participants and setting: Four focus group interviews were conducted with 26 rural patients and carers in south-west Victoria between September and December 2012. Frequent users of general practice were recruited from local allied health self-management programs and a mothers' group. Focus groups were audio recorded, transcripts were independently analysed and interpreted using narrative methodologies.
  15. Content Article
    High quality handovers are essential for safe healthcare and are used in many clinical situations. Miscommunication during handovers can lead to unnecessary diagnostic delays, patients not receiving required treatment, and medication errors. Miscommunication is one of the leading causes for adverse events resulting in death or serious injury to patients. The process of handovers can be improved, and the aim of this article is to provide practical guidance for clinicians on how to do this better.
  16. Content Article
    Chronic diseases account for an estimated 86% of deaths and 77% of the disease burden in the WHO European Region, as measured by disability-adjusted life-years. These diseases, including cardiovascular diseases, cancer, diabetes, obesity and chronic respiratory diseases, are now the largest cause of death and disability worldwide. This development is bringing about a fundamental shift in health systems and health care and thus in the roles of patients.
  17. Content Article
    "Among many other opportunities created by the launch of the World Alliance for Patient Safety is the hope that one day the learning from the inadvertent death of a patient in a hospital in one country could save the lives of many others around the world."  In his paper, Sir Liam Donaldson (Chair of the WHO World Alliance for Patient Safety at the time) talks about the importance of global collaboration for patient safety.
  18. Content Article
    This Care Quality Commission (CQC) briefing document discusses the need for a change in the way that serious incidents are investigated and managed in the NHS. It is based on the findings of a review of a sample of serious incident investigation reports from 24 acute hospital trusts. This sample represented 15% of the total 159 acute hospital trusts in England at the time of review. The briefing provides a summary of the findings, linked to five opportunities for improvement and calls for all organisations to work together across the system to align expectations and create the right environment for open reporting, learning and improvement.
  19. Content Article
    This guidance is issued by the Health and Safety Executive, the Institution of Engineering Technology and the British Computer Society. Following the guidance is not compulsory but if you do follow the guidance you will normally be doing enough to comply with the law in Great Britain where this is regulated by the Health and Safety Executive (HSE). HSE inspectors seek to secure compliance with the law and may refer to this guidance as illustrating good practice.
  20. Content Article
    In a new instalment of the Profiles in Improvement series from the US based Institute for Healthcare Improvement (IHI), Patricia McGaffigan describes her healthcare journey and why the safety movement needs a “reboot.”
  21. Content Article
    An audio recording of Harry Cayton, Chief Executive of the Professional Standards Authority, speaking at the Kings Fund conference, Patient voice and power in the new NHS. Harry talks about the importance of the patient voice and the impact that different leadership styles can have within the NHS. A transcript is also available to download.
  22. Content Article
    In 2004, the Agency for Healthcare Research and Quality (AHRQ) released the Hospital Survey on Patient Safety Culture (SOPS™ Hospital Survey) for providers and other staff to assess patient safety culture in their hospitals. Since then, hospitals across the United States and internationally have implemented the survey. In 2019, AHRQ released a new version, the SOPS Hospital Survey 2.0. The original survey is still available; however, the use of version 2.0 is encouraged.
  23. Content Article
    Patient Safety: Making health care safer illustrates the importance of safe care for everyone, what the burden and impact of unsafe care is, and WHO’s approach to tackling the issue of unsafe care. The brochure also contains a comprehensive collation of key WHO materials and activities in to generate improvements at the front line.
  24. Content Article
    The Public Interest Disclosure Act 1998 (PIDA) protects workers by providing a remedy if they suffer a workplace reprisal for raising a concern which they believe to be genuine. 
  25. Content Article
    "...many factors can hinder effective implementation, including: failure to appreciate the complexity of a problem or the context in which change is required; complicated or unclear guidance; or using an inappropriate method of dissemination such as top-down instruction." In this blog for the Kings Fund, Suzette talks about the barriers to implementation and the importance of choosing the right approach.
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