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Showing results for tags 'Just Culture'.
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Content ArticleThe ‘No Blame Culture’ being adopted by the NHS draws attention from individuals and towards systems in the process of understanding an error. This article in the Journal of Applied Philosophy argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. The authors argue that proponents of No Blame Culture often fail to distinguish between blaming someone and holding them responsible, They examine the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, the authors argue that a responsibility culture has significant advantages over a No Blame Culture as it can enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.
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This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Jonathan talks to us about the importance of leadership in creating a safety culture and the role of Patient Safety Learning in fostering collaboration and establishing standards for patient safety. -
EventDr Leslie Hamilton, assistant coroner and retired cardiac surgeon, will speak about the importance of creating and maintaining a no-blame culture within NHS and independent healthcare organisations. This should help to ensure that people feel able to share and reflect honestly whenever things go wrong in care, so that lessons can be learnt and changes made to improve patient safety. Register
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In this article, published in the Future Healthcare Journal, Helen Hughes, Chief Executive of Patient Safety Learning, reflects on how avoidable harm continues to occur, ten years on from the Francis report into major patient safety failings at Mid Staffordshire NHS Foundation Trust. She describes an implementation gap—where safety concerns and issues highlighted in inquiries and reviews are not being translated into improvements in patient safety. The article outlines some of the key barriers to implementation and suggests what needs to change to ensure we truly learn lessons from patient safety scandals such as Mid Staffordshire. -
Content ArticleA just and learning culture is the balance of fairness, justice, learning–and taking responsibility for actions. It is not about seeking to blame the individuals involved when care in the NHS goes wrong, nor the absence of responsibility and accountability. This report by NHS Resolution aims to promote the value of a person-centred workplace that is compassionate, safe and fair.
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Content ArticleIn this blog, Jennifer Nelson investigates why doctors have one of the highest suicide rates of any profession. She speaks to experts including health psychologist Jodie Eckleberry-Hunt, who highlights that doctors tend to have a lower level of cognitive flexibility, which may affect their ability to cope when things don't go to plan. Psychotherapist Brad Fern goes on to describe the complex range of reasons that doctors may take their own lives, and describes the importance of tackling silence and isolation among doctors. The blog concludes by addressing the need to separate suicide from other wellbeing issues doctors might face, and by looking at how the system itself contributes to high suicide rates.
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Content ArticleThis document by the Joint Commission provides an overview of the issues faced by healthcare workers who are negatively affected by their involvement in a patient safety incident—second victims. It highlights the prevalence of second victims, summarises the key problems they face and outlines recommendations to ensure staff receive adequate support from healthcare organisations when they are involved in an incident.
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This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Lucy and Rebecca talk to us about their experience as Patient Safety Incident Response Framework (PSIRF) early adopters. They discuss how PSIRF puts patients at the centre of incident investigations, and the challenges and opportunities they have faced in implementing PSIRF at West Suffolk NHS Foundation Trust.- Posted
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Content ArticleHealthcare relies on high levels of human performance; however, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. This narrative review in the journal Anaesthesia aims to describe what is known about human factors in anaesthesia to date.
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Content ArticleThis poster produced by researchers at Warwick Medical School summarises a qualitative research project that examined attitudes and behaviours related to patient safety culture at a single West Midlands Trust. The study's objective was to gain an understanding of staff’s views regarding the culture within the Trust and of their attitudes and behaviours when reviewing clinical incidents and mortality and morbidity. The poster was a winner at the HSJ Patient Safety Congress 2022 in the category 'A just culture for learning and change'. Read the full research paper.
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Content ArticleThis article in BMJ Open Quality aimed to improve patient safety by examining the organisational and individual factors that contribute to adverse events, enabling corrective action so that errors are not repeated. Using interviews and observations of Trust meetings at a single Hospital Trust in the Midlands, England, this qualitative study: analysed whether the attitudes and behaviours of clinicians and managers are aligned with a Just Culture. identified barriers and enablers to an organisation adopting a Just Culture. The study found evidence of a fair incident management process within the Trust; however, there was no agreed vision of a Just Culture and the majority of the staff were unfamiliar with the term. Negative perspectives relating to clinical incidents and their management persist among staff with many having concerns about being the subject of an investigation and doubts about whether they drive improvement.
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Content ArticleIn this editorial. Peter Walsh reflects on 20 years as Chief Executive of Action against Medical Accidents (AVMA) as he retires from the role. AvMA also marks its 40th anniversary this year, and Peter examines the organisation's unique role in focusing on patient safety and justice for patients. He highlights that healthcare systems and patient safety practice still have a long way to go in offering fairness and support to families affected by avoidable harm in healthcare, and argues that focusing on patients and their families must be a top priority when looking at system safety. He highlights the vital role that AvMA has played in bringing Duty of Candour into law in the countries of the UK, and argues that legal action is an important right that must be retained for patients and families who have come to harm as a result of medical error. He also talks about AvMA's recent development of a Harmed Care Pathway in collaboration with the Harmed Patients Alliance, which outlines the specific set of needs that should form part of a package of care for harmed patients and families.
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Content ArticleA recently published report highlights the shortcomings in care provided by the NHS. Peter Walsh, Joanne Hughes and James Titcombe emphasise how millions could be saved if people were empowered early on to have their needs met without the need to turn to litigation
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Content ArticleThis editorial by Barbara Fain, Chief Executive of the Betsy Lehman Center in Massachusetts, highlights the need to focus on system safety and moving away from a culture of individual blame, in order to improve patient safety. Referring to the case of nurse RaDonda Vaught who was convicted of negligent homicide for a medication error at a Tennessee hospital, Barbara looks at research that demonstrates that people generally believe the best way to reduce the likelihood of medical errors is by choosing the right doctor, and argues that this cultural belief played into Vaught's conviction. She highlights the need to use evidence-based strategies to communicate with healthcare professionals and the public about the wider picture of patient safety and systems thinking.
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Content ArticleAdam Tasker spent over a decade in the Royal Navy before starting medical training at the University of Warwick. In this article for BMJ Leader, he reflects on a near miss incident that he was involved in while working as a Helicopter Warfare Officer, examining his attitudes and those of his colleagues, and the practices and behaviours of the squadron’s leaders. He compares his experience in the Royal Navy to that of his experience as a medical student, and identifies lessons that are relevant to medical training, professional expectations and the management of clinical incidents. These lessons aim to support the implementation of a Just Culture within the NHS.
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Published on 19 October 2022, the report of the investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. The investigation found that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed. In this article, Patient Safety Learning analyses the findings of this report from a broad patient safety perspective, focusing on five key themes that are consistent with many other serious patient safety inquiries and reports in recent years. It sets these in their wider context and highlights the need for a fundamental transformation in our approach to patient safety if similar scandals are to be prevented in the future.- Posted
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Content ArticleThe NHS Patient Safety Strategy aims to monitor and support the development of a strong patient safety culture within the NHS, creating an environment where individuals feel they will be treated fairly and compassionately if they speak up. In this publication, NHS England collates insights from focus groups held with NHS organisations that are rated by the Care Quality Commission as outstanding or good for its ‘Safe’ assessment domain. The insights reflect what they have done to support a patient safety culture within their organisations.
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This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Tracey talks to us about the role of NHS Supply Chain in ensuring the products procured through the NHS Supply are of high quality and are safe for healthcare organisations to use. She also highlights the vital importance of complaints and the need for staff who don’t work in direct care delivery to recognise their role in patient safety. -
Content ArticleMersey Care Foundation Trust's development of a respect and civility agenda has been shortlisted for several national awards. They have developed a free course called Just and Learning Culture: A New Way of Caring, which is aimed at HR colleagues but is accessible to everyone. You can read more about their work, and access the course (scroll to the bottom of the page) via the link below.
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Content ArticleIn this 3.5 minute film, Mersey Care looks at what bullying is and how it can have a devastating impact on staff. It forms part of their work to encourage people to feel safe in speaking up about bullying and build a positive working environment.
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on errors and designing system-based solutions to improve patient safety. Key learning objectives: Understand what Human Factors are Learning from incidents Designing system-based solutions Preventing human error Blame and psychological safety Just culture Register
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Content ArticleThis paper, summarised in the Journal of Hospital Administration, concludes: "Embedding Restorative Just Culture and Safety II concepts into the incident review process is associated with improved measures of culture and review outputs. The integration of Safety II concepts and support of cultural shifts will require further work and committed leadership at all levels."
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Content ArticleThe Resilient Surgeon is a podcast by The Society of Thoracic Surgeons in the US. In this episode, Dr Michael Maddaus interviews Dr Amy Edmondson, a scholar of leadership, teamwork and organisational learning. Dr Edmondson defines psychological safety as a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes. It makes a team a safe place for interpersonal risk-taking. In this podcast, she explains how psychological safety is the key to unlocking high quality conversations that result in improved team outcomes.
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Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
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Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views? -
Content ArticleRepeated culture of safety surveys of the nursing staff at Children’s Hospital of Philadelphia’s main campus demonstrated lagging scores in the domain of nonpunitive responses to error. The hospital had tried for many years to address the problem using a variety of strategies, including small group training sessions on just culture for staff and leaders, but had met with limited success. Finally, in 2015, it committed to trying something genuinely different—even perhaps disruptive—that might actually shift the stagnant metrics. Their novel, multifaceted programme, implemented over a two-year period, yielded a 13% increase in staff rating scores that the hospital has been able to sustain over the subsequent two-year period. The design and rollout of our program was neither simple nor smooth, but valuable lessons were learned about realistic, operational implementation of principles of psychological safety in a large and complex clinical organisation. In this paper, Neiswender et al. describe the programme and the lessons learned in the journey from idea inception to post-implementation.
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