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Content ArticleThe World Health Organization designated September 17 as World Patient Safety Day — a day, every year, to raise awareness of healthcare safety and reiterate its importance. This year the Patient Safety Movement hosted a four-hour virtual event as part of their #uniteforsafecare public awareness campaign. They organised the event to bring the public into the fold as well as unite patients, advocates, health workers and leaders together globally — working to ensure patient and health worker safety internationally. Here are 11 takeaways for the public, patients and their families from the #uniteforsafecare virtual event.
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Content ArticleWhy is it hard for a highly trained professional to speak or report about mistakes made by him or her? Jean-Pierre Kahlmann, a retired Military and Airline Pilot, and now Co-owner and CEO of Yes Human Factors Ltd, believes that every staff member in an organisation should feel safe to use her or his voice to speak about safety issues, mistakes and how to learn and improve. In this TEDx presentation, Jean-Pierre takes you on a trip through his Airforce and civil aviation career to show the added value of Just Culture in high reliability organisations. He talks about his, initial, internal resistance against speaking about his mistakes and he sees the same resistance within the culture of health care professionals.
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Content ArticleKatie Evans-Reber, Head of People at Wonolo, shares her insights on how leaders can make frontline workers from all organisations feel part of the team and how to create a positive organisation culture.
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Content ArticleWe all want passionate employees. We want them to care about their jobs and go that extra mile for our company. We also want them to have the confidence to speak up if they think it’s necessary — whether it’s to question a given workplace process or ask a question about the nature of their SMART objectives. Of course, not all employees will stand up and make themselves be heard. So what makes some employees suffer in silence while others are emboldened to stand out from the crowd? The answer is psychological safety. A psychologically safe workplace cultivates a work environment where team members have the freedom to speak out. This environment thrives on mutual respect and encourages co-workers to share their ideas and thoughts without the fear of being shot down or ignored. The obvious effects of psychological safety are better employee wellbeing and mental health. . Stuart Hearn, a performance management specialist, gives his three examples of change that can improve the level of psychological safety in the workplace.
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Content ArticleBubble PAPR is an innovative PPE respirator designed to keep NHS staff safe while caring for patients during COVID-19. In this video, Brendan McGrath, an NHS Intensive Care Consultant, describes how Manchester University Foundation Trust, Manchester University and Designing Science Ltd came together to re-invent the Powered Air Purifying Respirator for the covid era.
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Content ArticleFor some, the day we learned of our rare disease diagnosis is a happy day. Odd, isn’t it? Imagine having your closest friends and family thinking that you are overreacting a bit, or that you are searching for some attention? It might be frustrating! Having a diagnosis can be very important, not only in order to consider medical needs, but sometimes it can also come as proof that something is happening to the body, proof to others that there is something going on. Several people across the globe, with different rare diseases, have shared their story, telling us about needing to be heard and understood.
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Patient Safety Movement: Informed consent blog
Patient Safety Learning posted an article in Consent issues
Clinicians often have competing priorities in the clinical setting which hinder their ability to provide time for thorough dialogue with patients. Often, this dialogue contains information about procedures or processes for which the patient needs a thorough understanding in order to make an informed decision. Due to the lack of time, sometimes this informed consent process is passed from the clinician to the medical assistant or nurse. Furthermore, clinicians are increasingly facing pressure to visit with more and more patients, thereby cutting the time with each one shorter and shorter. Therefore, typically only the most essential information is discussed with the patient during these short times and often, education doesn’t make the cut. This asymmetrical information makes it difficult for patients to make informed decisions about their care and may create situations with unforeseen consequences. These workflow barriers within the system itself make it extraordinarily difficult for clinicians to effectively explain and discuss informed consent with their patients. -
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Why learn from everyday work? (Steven Shorrock, 2020)
Sam posted an article in Improving patient safety
For a few reasons – especially regulatory requirements – the majority of effort when it comes to safety management concerns abnormal and unwanted outcomes, and the work and processes in the run up to these. We need to learn from incidents – for moral, regulatory and practical reasons. But incidents alone don’t tell us enough about the system as a whole. If we view incidents as the tip of the iceberg in terms of total hours of work or total outcomes, then what lies beneath? Steven Shorrock explores this in an article for HindSight. -
Content ArticleA conversation with John Wilkes (AstraZeneca), Clifford Berry (Takeda), Amy D. Wilson, Ph.D. (Biogen), and Jim Morris (NSF Health Sciences). This article is the first part of a two-part roundtable Q&A focused on human performance in pharmaceutical operations. Part 1 discusses key drivers for human performance improvement, compares lean manufacturing and human performance programmes, and provides perspectives on human performance in the context of the rapid scale-up and production of COVID-19 therapeutics and vaccines. Part 2 reviews human performance in the context of company investigation and CAPA programmes.
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Content ArticlePeter Walsh, Chief Executive of Action against Medical Accidents (AvMa), guest blogs for the Professional Standards Authority, setting out the key priorities AvMa would like to see as part of regulatory reform to ensure patients have a voice.
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Content ArticleThe Accessible Information Standard directs and defines a specific, consistent approach to identifying, recording, flagging, sharing and meeting individuals’ information and communication support needs by NHS and adult social care service providers.
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Content ArticleA team of scientific experts has joined forces from across the world to help fight the spread of misinformation about the COVID-19 vaccines. Together they have created a unique online guide, led by the University of Bristol, to arm people with practical tips combined with the very latest information and evidence to talk reliably about the vaccines, constructively challenge associated myths, and allay fears. With the race on to vaccinate as many people as possible soonest in the wake of a more virulent virus strain, they’re appealing to everyone, from doctors to politicians, teachers to journalists and parents to older generations, to understand the facts, follow the guidance, and spread the word.
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Content ArticleDuring the festive period, Father Christmas has the busiest 24 hours of his year delivering Christmas presents across the world. While this seems an insurmountable task, for him it’s all in a night’s work, facilitated by applying human factors (HF) in many areas. However, as with healthcare, there is always room for reflection, learning and improvement for the benefit of consumers... Feature from Peter A Brennan and Rachel S Oeppen in the BMJ's Christmas 2020: Dr Strange.
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The Patient Safety Learning hub has provided the vehicle through which I’ve shared my personal journey as I sought to establish and embed a second victim support initiative at the trust where I worked until my recent retirement. Four years ago SISOS was set up to ensure that colleagues affected by safety incidents received emotional support as soon as possible. A lot of lessons have been learned along the way and positive actions taken. These are my personal thoughts. -
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Quality improvement from the dining room table
Claire Cox posted an article in Blogs and vlogs
Since her last blog for the hub, Claire has moved away from clinical practice as a critical care outreach nurse and has entered the world of patient safety management in a new Trust. Coming out of a second lockdown, Claire reflects on how her experiences working in the NHS are very different from the first lockdown back in March 2020 and the difficulties she's facing doing quality improvement from home. -
Content ArticleThe Care Quality Commission (CQC) were commissioned by the Department for Health and Social Care to conduct a special review of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions taken during the COVID-19 pandemic. This interim report sets out the progress of our review so far and our expectations around DNACPR.
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Patient Safety Authority: Health literacy
Patient Safety Learning posted an article in Improving patient safety
Structuring and presenting healthcare information that aligns with a patient’s level of understanding can help patients achieve optimal outcomes. Verbal communication strategies such as “teach back” and “Ask Me 3®” programmes and written strategies address opportunities identified in the event reports and may help improve patient understanding and engagement in their care. The Patient Safety Authority have collated guidance, resources and education tools on health literacy. -
Content ArticleEast Lancashire Hospitals NHS Trust (ELHT) is a healthcare provider treating over half a million patients a year in the North West. Back in 2013, they were investigated as part of the Keogh Review and as a result were categorised as an organisation in “special measures”. Morale amongst the staff consequently hit rock bottom, against a backdrop of negative media articles. Staff engagement was identified as a fundamental driver to improve staff and patient experience. However, it was appreciated that the cultural change required would take time to achieve. To gain regular feedback from their staff, they used the Staff Friends and Family Test (Staff FFT), to which they added several local questions. Based on this feedback and information from the NHS Staff Survey, they set about rebuilding ELHT with the clear intention to create a culture where staff felt they belonged. Read their case study.
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Content ArticleThe Comprehensive Unit-based Safety Program (CUSP) aims to improve the culture of safety while providing frontline caregivers with the tools and support that they need to identify and tackle the hazards that threaten their patients at the unit or clinic level. Developed by Johns Hopkins safety and quality researchers, the five-step programme has been used to target a wide range of hazards, including patient falls, hospital-acquired infections, medication administration errors, specimen labeling errors and teamwork and communication breakdowns. Notably, CUSP has been used in national and international quality improvement projects that have drastically reduced hospital-acquired infections. Whether your hospital has participated in such projects or is seeking to adopt CUSP, the Armstrong Institute provides resources to help you run a successful programme.
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Content Article
ARHQ: The CUSP Method
Patient Safety Learning posted an article in Improving patient safety
The Comprehensive Unit-based Safety Program (CUSP) is a method that can help clinical teams make care safer by combining improved teamwork, clinical best practices, and the science of safety. The Core CUSP toolkit gives clinical teams the training resources and tools to apply the CUSP method and build their capacity to address safety issues. A number of toolkits are available to help clinical teams adopt the CUSP method to make care safer. Most teams will want to start with the Core CUSP Toolkit to learn key principles of the CUSP method. Once you’ve learned the basics, additional toolkits can help you target certain safety issues in specific settings of care. Created for clinicians by clinicians, the Core CUSP toolkit is modular and modifiable to meet individual unit needs. Each module includes teaching tools and resources to support change at the unit level, presented through facilitator notes that take you step by step through the module, presentation slides, tools, and videos. -
Content ArticleThe latest newsletter from the Patient Safety Authority highlights the importance of stronger warnings on medications, tracking the way misinformation spreads online, treating brain conditions through art and music, and more.
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Content ArticleA new toolkit to support GPs to deliver care for patients with hearing loss and aims to encourage deaf patients to access primary care, has been launched. The educational kit, developed by Royal College of GPs (RCGP) in collaboration with the UK’s largest hearing loss charity, RNID and NHS England and Improvement aims to support GPs to consult effectively with deaf patients by offering tips on how to communicate during face to face and remote appointments. It also offers guidelines on how to recognise early symptoms of hearing loss and how to refer patients for a hearing assessment. The project aims to support GPs implement the latest NICE Guidelines, NHS Accessibility Quality Standard and Guidance across the UK. Resources include an Essential Knowledge Update (EKU) Screencast, GPVTS Teaching Powerpoint, Podcasts, Hearing Friendly Practice Charter for your GP Surgery to sign up to, EKU Online E-learning Module, RCGP Accredited Deaf Awareness Online Course, Hearing Friendly Practice Animation Video and much more.
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Content ArticleWith delays to promised support and trusts accused of penalising staff during their recovery, HSJ dig into why the NHS must provide support sooner rather than later for those experiencing Long-COVID. Patient Safety Learning has recently published a blog calling for better information and engagement with patients who have Long COVID: Clear NHS plan needed to reassure Long COVID patients. We have also co-produced a patient information leaflet with the Royal College of General Practitioners, to help patients understand what they can expect from their GP. To listen to the HSJ podcast, click on the link below.
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Content ArticleSarah Seddon's son (Thomas) was stillborn in May 2017. The lack of candour following Thomas’ death and the conduct of the serious incident investigation impacted significantly on Sarah and her family. The local investigation was followed by a Fitness to Practise (FtP) investigation where Sarah experienced how damaging, dehumanising and traumatic FtP processes can be for patients who are required to be witnesses. Here she reflects on the impact of being a witness in a Fitness to Practise (FtP) hearing had on her.
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Content ArticleDuring the COVID-19 pandemic, health care leaders are working to support staff who are experiencing anxiety, stress, and intense demands. This guide from the Institute of Healthcare Improvement (IHI), which builds on the IHI Framework for Improving Joy in Work, includes actionable ideas that leaders can quickly test during the coronavirus response, and which can build the longer-term foundation to sustain joy in work for the health care workforce.
