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Found 197 results
  1. Content Article
    The appointment of a Freedom to Speak Up (FTSU) Guardian is a requirement of the NHS Standard Contract in England. The National Guardian’s Office (NGO) provides leadership, support and guidance to FTSU Guardians. Guidance on recording data was originally issued in January 2017 and guardians in trusts and foundation trusts have been asked to provide quarterly reports on the number of cases they have received since April 2017. These quarterly reports have been published on the NGO’s webpages. This end of year report represents a summary and analysis of the second year’s return and compares across the two years for which data is available. 
  2. Content Article
    This article is from the US-based organisation - The Joint Commission, published by Sentinel Alert Event. The Joint Commission’s Sentinel Event Database reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events – from wrong site surgery to delays in treatment.
  3. Content Article
    In this article, Prof Chris Frerk, Consultant Anaesthetist at Northampton General Hospital and trustee of the Clinical Human Factors Group explains what to do when things don’t go according to plan and we can learn from airway events.
  4. Content Article
    Elisabeth Poorman argues that becoming a doctor means learning that mistakes are not acceptable. From study through to practice, doctors are told in ways big and small, the only way to be a good doctor is to be a perfect doctor. The pressure only intensifies when real harm is on the line. The encouraged response is to study harder, sleep less, and never admit fear. 
  5. Content Article
    A dilemma is a situation in which a difficult choice has to be made between two or more alternatives, especially ones that are equally undesirable. Healthcare is full of dilemmas as a result of the huge number of stakeholders with conflicting goals, multifaceted interactions and constraints, and multiple perspectives, which change daily. Dilemmas are created when safety conflicts with productivity, cost efficiency, and flow. A focus on one patent’s safety may conflict with a focus on all patients’ safety. It is vital that the different stakeholders talk to expose dilemmas and reveal the hidden trade-offs or adjustments that are kept secret because people are fearful of the consequences. Articulating dilemmas helps us to find a way to bring people with different interests and incentives into a conversation that meets everyone’s needs.
  6. Content Article
    The language we use in healthcare can have a huge impact on our patients and families. What we say and how we say it could have a negative or a positive impact. As clinicians we need to be mindful in how we say things and relay information. This short blog illustrates this.
  7. Content Article
    When Julie Bailey took her mother, Bella, into Mid Staffs Hospital in September 2007 she had no idea that her life was about to change forever. Over the next eight weeks she would witness such shocking neglect and abuse of elderly, vulnerable patients that the memories would haunt her for the rest of her life. And over the next five years she would uncover a culture of deceit and denial going right to the top of the NHS. From Ward to Whitehall is the story of Julie s fight for the truth to be uncovered about the deadly failings at Mid Staffs Hospital and her struggle to ensure that the tragedy would never be repeated.
  8. Content Article
    Conquer the most essential adaptation to the knowledge economy The Fearless Organisation: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth offers practical guidance for teams and organisations who are serious about success in the modern economy. With so much riding on innovation, creativity, and spark, it is essential to attract and retain quality talent--but what good does this talent do if no one is able to speak their mind? The traditional culture of "fitting in" and "going along" spells doom in the knowledge economy. Success requires a continuous influx of new ideas, new challenges, and critical thought, and the interpersonal climate must not suppress, silence, ridicule or intimidate. Not every idea is good, and yes there are stupid questions and yes dissent can slow things down, but talking through these things is an essential part of the creative process. People must be allowed to voice half-finished thoughts, ask questions from left field, and brainstorm out loud; it creates a culture in which a minor flub or momentary lapse is no big deal, and where actual mistakes are owned and corrected, and where the next left-field idea could be the next big thing. This book explores this culture of psychological safety, and provides a blueprint for bringing it to life. The road is sometimes bumpy, but succinct and informative scenario-based explanations provide a clear path forward to constant learning and healthy innovation. Explore the link between psychological safety and high performance Create a culture where it's "safe" to express ideas, ask questions, and admit mistakes Nurture the level of engagement and candour required in today's knowledge economy Follow a step-by-step framework for establishing psychological safety in your team or organisation Shed the "yes-men" approach and step into real performance. Fertilise creativity, clarify goals, achieve accountability, redefine leadership, and much more. The Fearless Organisation helps you bring about this most critical transformation.
  9. Content Article
    This presentation is called Families as Partners in Achieving Safer Care and is delivered in this short film by Kath Evans, Head of Patient Experience – Maternity, Newborn, Children and Young People, NHS England.
  10. Content Article
    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.
  11. Content Article
    The objective of this research paper, published in the Journal of the Royal Society of Medicine, was to investigate doctors’ intentions to raise a patient safety concern by applying the socio-psychological model ‘Theory of Planned Behaviour’.
  12. Content Article
    When someone you love is hospitalised, it can be scary-even terrifying-for the patient and for family and friends. A hospital may seem like a foreign land. Sounds, smells, and the culture are unfamiliar; even the medical terminology sounds like a different language. Understanding the hospital environment and knowing how to navigate its complicated pathways can make you a strong champion for your loved one. You are as critical to your loved one's recovery as the doctors and nurses. Your role is different, but vital. In some cases, you can make the difference between life and death. Hospital Warrior de-mystifies the process and provides the tools, understanding and insight you need to get the best care for your loved one.
  13. Content Article
    Going to an appointment with your doctor can be a daunting experience. You may have a million questions to ask, but as soon as you get into the room they are forgotten or you feel you are unable to ask them. This blog, written by Bonnie Friedman and published by Fit for Joy, describes techniques you could use to enable your voice to be heard at consultations.
  14. Content Article
    In his blog, published by onthewards website, Joe Farmer (a doctor working in psychiatry) discusses rudeness in the workplace and the impact it can have on clinical performance and subsequently patient safety.
  15. Content Article
    Workplace 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. 
  16. Content Article
    Effective communication is critical for patient safety. One potential threat to communication in the operating room is incivility. Although examined in other industries, little has been done to examine how incivility impacts the ability to deliver safe care in a crisis. In this US based study, the authors sought to determine how incivility influenced anaesthesiology resident performance during a standardised simulation scenario of occult haemorrhage.
  17. Content Article
    ECRI Institute's mission is to protect patients from unsafe and ineffective medical technologies and practices. More than 5,000 healthcare institutions and systems worldwide, including four out of every five U.S. hospitals, rely on ECRI Institute to guide their operational and strategic decisions.
  18. Content Article
    The National Patient Safety Agency developed the Incident Decision Tree to help NHS managers in the UK to determine a fair and consistent course of action toward staff involved in patient safety incidents. Research shows that systems failures are the root cause of the majority of safety incidents. Despite this, when an adverse incident occurs, the most common response is to suspend the clinician(s) involved, pending investigation, in the belief that this serves the interests of patient safety. The Incident Decision Tree supports the aim of creating an open culture, where employees feel able to report patient safety incidents without undue fear of the consequences. The tool comprises an algorithm with accompanying guidelines and poses a series of structured questions to help managers decide whether suspension is essential or whether alternatives might be feasible. 
  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
    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.
  21. Content Article
    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! 
  22. Content Article
    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.
  23. Content Article
    Amy Edmondson, PhD, Harvard professor and speaker at Learn Serve Lead 2019: The AAMC Annual Meeting, talks about how to create an interpersonal climate that encourages input from all members of the patient care team.
  24. Content Article
    Collaborative, inclusive and compassionate leadership is essential to deliver the highest quality care for patients and tackle deep-seated cultural issues in the NHS, including unacceptable levels of work-related stress, bullying and discrimination. Staff are the NHS’s greatest asset, but a number of challenges are taking a significant toll on the workforce. In addition to severe workforce pressures, including large numbers of staff vacancies, surveys have shown that staff experiences of working in the NHS can be very negative. In the 2018 NHS staff survey, 40 per cent of NHS staff reported feeling unwell as a result of work-related stress in the previous 12 months, 13 per cent said they had experienced bullying or harassment from managers and 19 per cent experienced it from other colleagues. This article gives the response from the Kingsfund on the recent NHS staff survey.
  25. Content Article
    Steve Turner is a healthcare professional, a nurse prescriber with experience in senior management in both the NHS and private sectors. He works as a clinician with vulnerable adults on the margins of society.  In this blog, published on Care Right Now, he reflects on the situation in England based on his experiences and those of the many people he has met as a result. All of whom experienced the backlash that can happen when organisational reputation trumps patient safety. One thing many of us have in common is that, put simply, we never intended to become known as ‘whistleblowers’ we were just trying to do our job to the best of our ability.
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