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Found 220 results
  1. Content Article
    In this paper published in the Journal of Nursing Care Quality, Nadzam discusses why effective communication is critical during the countless interactions that occur among healthcare workers on a daily basis.
  2. Content Article
    John Dobbin is the editor of Thinking Digitally. Here he has written a blog on some of the barriers to psychological safety and why it is being ignored in the work place.
  3. Content Article
    In this article on The People Space, Megan Reitz, professor at Hult International Business School, outlines the TRUTH framework to help individuals, teams and organisations unpick their conversational habits and to both 'speak up' and 'listen up'.
  4. Content Article
    The highest performing teams have one thing in common: psychological safety – the belief that you won’t be punished when you make a mistake. Studies show that psychological safety allows for moderate risk-taking, speaking your mind, creativity, and sticking your neck out without fear of having it cut off – just the types of behaviour that lead to market breakthroughs.  This article in the Harvard Business Review suggests six practical points to create a psychologically safe environment. 
  5. Content Article
    A bold, original book that sheds new light on our understanding of the role courage plays in healthcare. Critically analysing both the positive and negative implications of the presence of courage in delivering care, the authors present literature, theory, and detailed examples from practice, including whistleblowers' own accounts of courage-demanding situations.  With a view to promoting better patient outcomes, well-being for practitioners, and support for those who feel compelled to ‘speak out’ and challenge bad practice, Courage in Healthcare is an invaluable resource for any healthcare practitioner working in the NHS today, a rallying call and a practical guide.  
  6. Content Article
    Pete Smith is nothing without the energy and commitment of the amazing people who surround him. Increasing the technical skill of a healthcare clinician makes for incremental change. Improve the culture within which they work, think and communicate and suddenly quantum change is possible. Two perioperative nurses from a regional hospital in Victoria, Australia, innovated a simple, elegant solution to the problem of noise and distraction in the operating room. Pete Smith was one of them.
  7. Content Article
    How offender healthcare is managed in prisons and in the community.
  8. Content Article
    Below Ten Thousand is a language-based safety tool for any clinical arena where 'noise and distraction' is a problem, and where high performance teams need to quickly gain 'situational awareness' and ‘directed focus’ in order to successfully navigate the perils of acute healthcare whilst providing first class interventions. 
  9. Content Article
    This blog highlights: The juxtaposition of how work is carried out by healthcare staff compared to the work that policy makers are 'imagining' healthcare workers are doing. The need for healthcare staff to be part of patient safety solutions.
  10. Content Article
    A brief, heartfelt piece presented purely from the harmed patient's perspective and urging those involved in making decisions about whether or not to investigate to consider the impact of a good investigation on the ability of the harmed patient and their family to heal... Well received on twitter and described by a number of patients as 'you've said what I feel'. A reminder that a crucial purpose of the investigation is to give a harmed patient and their family a full explanation to help them understand, process and share for learning their experience. All necessary to their recovery. All necessary to their own 'safety' following an incident (we know poor responses cause additional suffering to those already harmed). The author also highlighted (via twitter) how much of this blog relates to the needs of staff involved in incidents too...
  11. Content Article
    More than 30 years have passed since the near-fatal medication error but Michael Villeneuve recalls the moment with absolute clarity. Now the chief executive officer at the Canadian Nurses Association, Villeneuve frequently draws upon that experience in his day-to-day work to promote better care, better health and better nursing across Canada. Watch this short video, produced by the Canadian Patient Safety Institute (CPSI) to hear more about his experience. 
  12. Content Article
    This report by NHS Resolution provides an in-depth examination of these rare but tragic incidents and the investigations that follow them. For the purposes of this study they focused on 50 cases of cerebral palsy where the incidents occurred between 2012 and 2016 and a legal liability has been established. Working in partnership with other organisations, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, NHS England and NHS Improvement, NHS Resolution have highlighted areas for improvement and made clear recommendations to help trusts prevent further incidents. The study draws upon the unique data set NHS Resolution holds to address two key areas for improvement: training to prevent future incidents and the quality of serious incident investigations.
  13. Content Article
    This case story highlights the missed opportunities that could have prevented a cardiac arrest and subsequent severe hypoxic brain injury in an intensive care patient. 
  14. Content Article
    The preventable death of Connor Sparrowhawk in July 2013 led to a number of investigations and enquiries into practice at Southern Health NHS Foundation Trust in whose care he died.
  15. Content Article
    Communicating after harm in healthcare was developed by the Canadian Patient Safety Institute to assist organisations throughout the process of communicating after patient safety incidents that resulted in harm. 
  16. Content Article
    Toolkit for improving perinatal safety helps hospital labour and delivery units in the US improve patient safety, team communication, and quality of care for mothers and their newborns with an aim of decreasing maternal and neonatal adverse events resulting from poor communication and system failures.
  17. Content Article
    Interesting article, by the Patient Safety Network, around how patients can be involved in the solution and the cause of some patient safety incidents.
  18. Content Article
    This report states that patient and public engagement has been on the NHS agenda for many years, but the impact has been disappointing. There have been a great many public consultations, surveys, and one-off initiatives, but it argues that the service is still not sufficiently patient-centred. In particular, it looks at a lack of focus on engaging patients in their own clinical care, despite strong evidence that this could make a real difference to health outcomes. This paper argues that a more strategic approach is required to create the necessary shift in beliefs, attitudes and behaviours.
  19. Content Article
    The involvement of patients in their care is a top priority for the NHS, highlighted in the NHS Constitution and the NHS Five Year Forward View. Healthcare providers are encouraged to develop different relationships with patients and communities to help empower them and engage them in their care. This same approach applies to patient safety in healthcare, where greater engagement of patients is seen as one of the building blocks for improvement. .
  20. Content Article
    Potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies. This quality improvement study from Suliburk et al., published in JAMA Network Open, analysed the incidence of human performance deficiencies during the provision of surgical care to identify opportunities to enhance patient safety.
  21. Content Article
    The Patient Safety Network (PSNet) discuss a case of a 65 year old who went in for one operation, but ended up having a completely different operation.
  22. Content Article
    Designed and tested by the Institute for Healthcare Improvement's (IHI) world-renowned safety experts, this toolkit includes documents on improving teamwork and communication, tools to help you understand the underlying issues that can cause errors, and valuable guidance about how to create and maintain reliable systems. Each of the nine tools includes a short description, instructions, an example and a blank template.
  23. Content Article
    What patient safety beliefs get in the way of preventing harm? In this video, the Institute for Healthcare Improvement's (IHI) Frank Federico lists some common misunderstandings, including the tendency to think of the Institute of Medicine’s six quality aims for improvement in silos.
  24. Content Article
    Published in HSJ, Annie Laverty, Chief Experience Officer, Northumbria Healthcare Foundation Trust, speaks to Jeremy Taylor, former CEO of patient group National Voices, on the work her and the trust has done on patient experience, her motivation and the impact it has had.
  25. Content Article
    The lack of follow-up or communication of unexpected significant findings can have a serious or life-threatening impact on patients. This was seen in the reference case that informed this Healthcare Safety Investigation Branch (HSIB) investigation. In this event, a 76-year old woman had a chest X-ray showing a possible lung cancer which was not followed up and resulted in a delayed diagnosis. The patient died just over two months after her diagnosis.
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