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Showing results for tags 'Behaviour'.
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Content Article
Research shows that poor handover in hospitals puts patients at risk of severe harm
Anonymous posted an article in Handover
Research undertaken by digital health platform, CAREFUL shows that handover in hospitals is the cause of frequent and severe harm to patients.- Posted
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Content ArticleIn this episode of The Mind Full Medic podcast, host Cheryl Martin talks to Dr Chris Turner, a consultant in Emergency Medicine at University Hospitals of Coventry and Warwickshire. Chris is also the co-founder of Civility Saves Lives, an organisation dedicated to raising awareness of the impact behaviour has on individuals, teams and organisations. In this conversation, Chris discusses his own professional journey and experience as a healthcare leader and safety and quality lead. He talks about the challenging start to his consultant career, the powerful impact of a trusted mentor and critical friend, and how this experience has informed his future work. He also describes the spectrum of approaches to improving safety and quality in the challenging, complex healthcare environment, including the Safety I and Safety II approaches.
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Content ArticleTo find out how checklists and monitoring work in actual practice, Benjamin and Dismukes observed line operations during 60 flights conducted by three air carriers from two countries. They used a structured technique to observe and record checklist and monitoring performance, and situational factors that might affect performance. Because an important function of checklists and monitoring is to catch, or “trap,” operational errors, they also recorded deviations in aircraft control, navigation, communication and planning. When a deviation was observed, they tracked whether crewmembers identified and corrected it, and whether there were any consequences that might affect the outcome of the flight. They found that checklists and monitoring are not as effective as generally assumed.
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An encounter with an error trap by Steve Highley (6 August 2015)
Sam posted an article in Error traps
Steve Highley looks at responding positively to error using a personal experience involving his car and highlights how to find and deal with error traps.- Posted
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NHS Staff Survey 2020
Patient Safety Learning posted an article in Culture
The NHS Staff Survey is one of the largest workforce surveys in the world and has been conducted every year since 2003. It asks NHS staff in England about their experiences of working for their respective NHS organisations. Follow the link below for further information and to complete the survey. -
Content ArticleThe successful implementation of clinical practice guidelines should improve quality of care by decreasing inappropriate variation and expediting the application of effective advances to practice. However, despite wide promulgation, practice guidelines have had limited effect on changing physician behavior. Cabana et al. conducted a systematic review of the barriers to physician adherence to clinical practice guidelines, practice parameters, clinical policies or national consensus statements. They found that physician adherence is dependent on physician awareness (31 examples), agreement (68 examples), self-efficacy (13 examples), outcome expectancy (12 examples), motivation (3 examples), and the absence of external barriers to perform guideline recommendations (62 examples). The findings suggest that studies describing interventions to improve physician adherence may not be generalisable, since barriers in one setting may not be present in another. Using this analysis, the authors propose a framework which describes the barriers that must be overcome to improve physician adherence. This framework can be used (1) as a method to profile barriers or sources of poor adherence and thus (2) as a diagnostic tool to standardise and select appropriate interventions to improve adherence. The selection of interventions to change physician behaviour has been haphazard in the past. This analysis offers a more rational approach towards improving physician adherence to practice guidelines as well as a framework for further research.
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Content ArticleThe Association of Anaesthetists has published two posters highlighting what to do if you see unprofessional behaviours to make hospitals safer for patients and staff.
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- Staff safety
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Content ArticleThis blog from Samrina Bhatti, Manager, and Karen Taylor Director, Deloitte Centre for Health Solutions, celebrates World Patient Safety Day 2020 by exploring how the safety of health workers, is a priority for patient safety.
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Osmond Ergonomics: Posture guides
Patient Safety Learning posted an article in Patient safety in health and care
Agile working is on the increase and here to stay. This brings its own challenges for people working in a variety of locations and environments. Technology is pervasive and our technical interactions are migrating rapidly to mobile and hand-held devices, keeping us connected and able to work almost anywhere. This inevitably affects our posture and can lead to musculoskeletal issues in the longer term. Adopting the correct posture when sitting, standing and operating mobile devices aids the prevention and management of existing musculoskeletal problems. Regular stretching exercises are even more beneficial. Osmond Ergonomics provides support tools such as these free guides.- Posted
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Content ArticleA short article from NHS Education for Scotland about Significant event analysis (SEA). Enhanced SEA is a well-established safety improvement tool in general practice. However, there is good evidence to suggest that many SEAs are poorly conducted by practice teams, leading to missed opportunities to make health care safer.
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Content ArticleThe Cynefin framework is a conceptual framework used to aid decision-making. Created in 1999 by Dave Snowden when he worked for IBM Global Services, it has been described as a "sense-making device". Cynefin is a Welsh word for habitat. The Cynefin Framework allows executives to see things from new viewpoints, assimilate complex concepts, and address real-world problems and opportunities. Using the Cynefin framework can help executives sense which context they are in so that they can not only make better decisions but also avoid the problems that arise when their preferred management style causes them to make mistakes. In this video, Dave Snowden introduces the Cynefin Framework with a brief explanation of its origin and evolution and a detailed discussion of its architecture and function.
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Content ArticleNot all leaders achieve the desired results when they face situations that require a variety of decisions and responses. All too often, managers rely on common leadership approaches that work well in one set of circumstances but fall short in others. Why do these approaches fail even when logic indicates they should prevail? The answer lies in a fundamental assumption of organisational theory and practice: that a certain level of predictability and order exists in the world. This assumption, grounded in the Newtonian science that underlies scientific management, encourages simplifications that are useful in ordered circumstances. Circumstances change, however, and as they become more complex, the simplifications can fail. Good leadership is not a one-size-fits-all proposition as David J. Snowden and Mary E. Boone discuss in this article for the Harvard Business Review. They look at the 'Cynefin framework' which allows executives to see things from new viewpoints, assimilate complex concepts, and address real-world problems and opportunities.
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Error traps: Let’s raise awareness
Patient Safety Learning posted an article in Error traps
An error trap is a situation that could lead into avoidable harm if not mitigated. It is a situation where the circumstances in combination with human cognitive limitations make errors more likely.[1] Error traps can be found throughout health and social care in medicines, equipment and devices, in documentation, and in many other areas we see every day while going about our daily jobs in health and social care. We want to raise awareness of these error traps on the hub but more importantly we want to hear your suggestions of what needs to be done to prevent them and examples of where action has been take and worked. View our error trap gallery and share your examples.- Posted
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Content ArticleFounded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating healthcare organisations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission evaluates and accredits more than 22,000 healthcare organisations and programmes in the United States. The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them. The goals are to: Identify individuals served correctly Use medicines safely Prevent infection Identify individuals served safety risks.
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- Patient safety strategy
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Content ArticleThe Lilypond is a new conceptual model to describe patient safety performance. It radically diverges from established patient safety models to develop the reality of complexity within the healthcare systems as well as incorporating Safety II principles. There are two viewpoints of the Lilypond that provide insight into patient safety performance. From above, we are able to observe the organisational outcomes. This supersedes the widely used Safety Triangle and provides a more accurate conceptual model for understanding what outcomes are generated within healthcare. From a cross-sectional view, we are able to gain insights into how these outcomes come to manifest. This includes recognition of the complexity of our workplace, the impact of micro-interactions, effective leadership behaviours as well as patterns of behaviour that all provide learning. This replaces the simple, linear approach of The Swiss Cheese Model when analysing outcome causation. By applying the principles of Safety II and replacing outdated models for understanding patient safety performance, a more accurate, beneficial and respectful understanding of safety outcomes is possible.
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- Safety II
- Quality improvement
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Content Article
My experience of speaking up as a healthcare assistant in a care home
Anonymous posted an article in By health and care staff
A frank account from a healthcare assistant on the bullying she experienced after raising concerns at the care home she worked in.- Posted
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- Care home
- Care home staff
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Content Article
Re-consenting, an anonymous blog
Claire Cox posted an article in Consent issues
This anonymous blog high lights the vulnerability of patients, especially when it come to consent. This is a shocking account of events by a well informed patient when they were wrongly consented for a gynaecological procedure.- Posted
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- Consent
- Confidence
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Human factors and ergonomics in practice (2017)
Claire Cox posted an article in Recommended books and literature
This edited book concerns the real practice of human factors and ergonomics (HF/E), conveying the perspectives and experiences of practitioners and other stakeholders in a variety of industrial sectors, organisational settings and working contexts. The book blends literature on the nature of practice with diverse and eclectic reflections from experience in a range of contexts, from healthcare to agriculture. It explores what helps and what hinders the achievement of the core goals of HF/E: improved system performance and human wellbeing.- Posted
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- Latent error
- Confirmation bias
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Content ArticleHarold Shipman was an English doctor who killed approximately 15 patients while working as a junior hospital doctor in the 1970s, and another 235 or so when working subsequently as a general practitioner. Is it possible to learn general lessons to improve patient safety from such extraordinary events? In this paper, published in the US Journal of the Royal Society of Medicine, it is argued that it is not possible fully to understand how Shipman came to be such a successful and prolific serial killer, nor to learn how the safety of healthcare systems can be improved, unless his diabolical activities are studied using approaches developed to investigate patient safety.
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- Behaviour
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Content Article
Creating a safety culture
Claire Cox posted an article in Other countries and national agencies
A safety culture is built on trust. It empowers staff to report errors, near misses, and recognise unsafe behaviours and conditions that can put patients at risk, all of which drive improvement. This video by the Joint Commission Centre for Transforming Healthcare explains how they are engaging staff and the importance of speaking up. -
Content Article
Connor Sparrowhawk: The tale of laughing boy (2015)
Claire Cox posted an article in Patient stories
Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. This moving film describes what Connor was like by his friends and family and highlights the failings that caused the avoidable death of Connor.- Posted
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- Patient
- Patient death
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Content ArticleThis article, published by Forbes, looks at the airline industry and discusses the value in not only studying what pilots do wrong, but also what they do right. This can be translated into healthcare, we know lots about what has gone wrong in healthcare but not so much about the small, quiet things that go right. 'In aviation safety, it’s like we’ve been trying to learn about marriage by only studying divorce.' Written by Kirsty Kiernan a professor at Embry-Riddle Aeronautical University who teaches and conducts research in unmanned systems and aviation safety.
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- Behaviour
- Resources / Organisational management
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Content ArticleWorkplace incivility is low level and often not intended to cause harm. It can come from managers, colleagues and patients. Examples might include: eye rolling abrupt emails being interrupted, excluded or ignored hostile looks refusing to assist a colleague publicly criticising a colleague. See how incivility at work affects NHS staff and how that can impact negatively on patient safety. In this short film, join the staff of Epsom and St Helier University Hospitals NHS Trust on their journey as they reflect on the real-life effects of both incivility and active kindness.
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Content Article
A dropped instrument, washed in theatre and immediately reused: a story from a theatre nurse
Anonymous posted an article in By health and care staff
What happens if a surgeon accidentally drops an instrument on the floor, picks it up and reuses, without it going through a steriliser? Should this be allowed to happen? Well it did!- Posted
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- Anaesthetist
- Patient
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Content Article
A reflective account of the culture of fear
Anonymous posted an article in Bullying and fear
This is my story of how one bad experience can lead to another. We talk a lot about patients and their safety (quite rightly so) but very rarely do we hear about the healthcare professional who is going through turmoil and their mental health. This is my story.