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Showing results for tags 'Just Culture'.
Found 210 results
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Content ArticleHealthcare is recognised as a high-risk industry, involving complex systems, vulnerable individuals, and constantly evolving clinical treatments and healthcare products. This is the recording of a webinar hosted by NHS Supply Chain which looked at key patient safety issues in the NHS. It includes examples of learning related to patient safety and assurance priorities for safe healthcare products and services. Speaker panel: Helen Hughes, Chief Executive of Patient Safety Learning Tracey Cammish, NHS Supply Chain Heather Tierney-Moore OBE, NHS Supply Chain Dave Fassam, Healthcare Safety Investigation Branch (HSIB)
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Content ArticleThis article in BMJ Quality and Safety looks back at how the patient safety movement has developed over the last two decades. It argues that although the aim of the movement is to change systems, in reality this has not happened on a wide scale. The authors suggest that if we are to make quantitative improvements to patient safety, the next stage of the patient safety movement needs to prioritise substantive, system-wide change.
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Content ArticleThis briefing by NHS Supply Chain looks at shared learning on patient safety, and how collaborative working is enabling better assurance and safety for healthcare products and services. The briefing covers these topics: The role of NHS Supply Chain in patient safety Safety specifications for safer products System-level join up Human factors and just culture Case studies Overview of system partners Conclusion
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Content ArticleThis study in Risk Management and Healthcare Policy aimed to explore healthcare workers’ perceptions of patient safety culture at primary healthcare centres in the Eastern Province of Saudi Arabia, and the factors that influence them. It also aimed to identify the challenges of adopting patient safety culture in these centres. The study findings highlight a number of areas for improvement, particularly in relation to event reporting, non-punitive responses, and openness in communication. The authors highlight that error reporting should not just be considered a means of learning from mistakes, but should also be considered the first step towards preventing injury and improving patient safety. They highlight the need to eliminate three crucial elements associated with errors - blame, fear, and silence - in order to build a safety culture.
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This is the first in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Josie tells us about the nursing error that first sparked her interest in patient safety, how a just culture helps healthcare workers and systems learn from their mistakes, and how her love of skiing has inspired her to think differently about risk in healthcare. -
EventThere are a number of circumstances that compromise a clinician’s ability to provide safe care, such as unfollowable policies, malfunctioning equipment, or a culture of blame when something goes wrong. In some cases, these system-based factors force clinicians to step outside of the standard of care. Panelists will discuss how to apply the Just Culture framework to inform improvements when the standard of care is not followed and will describe the data that can identify system failures before harm occurs. Register
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Content ArticleThis systematic review in Nursing Open synthesises the best available evidence on the impact of nurses' safety attitudes on patient outcomes in acute care hospitals. The review included nine studies and found that nurses with positive safety attitudes reported: fewer patient falls and medication errors fewer pressure injuries and healthcare-associated infections fewer mortalities fewer physical restraints and vascular access device reactions higher patient satisfaction. The authors also found that effective teamwork led to a reduction in adverse patient outcomes. They conclude that a positive safety culture results in fewer reported adverse patient outcomes, and that nurse managers can improve nurses' safety attitudes by promoting a non-punitive response to error reporting and promoting effective teamwork and good communication.
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Content ArticleToo often in healthcare, when effective solutions to prevent avoidable harm are found, there is a lack of means to share these more widely. This gap between learning and implementation means that while we may we know what improves patient safety, this information can often remain siloed in specific organisations and health care systems. This results in patients continuing to experience harm from problems that have already been addressed by others. This article published in the Journal of Patient Safety and Risk Management describes how the charity Patient Safety Learning created the hub, a platform to encourage and support shared learning for patient safety. Designed by and for patient safety professionals, clinicians and patients, the hub offers a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make care safer for patients.
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Content Article
'Whistleblowing': a definition for reflection in Speak Up Month
Steve Turner posted an article in Whistle blowing
It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."- Posted
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Content ArticleNumerous studies show a link between a positive safety culture (where safety is a shared priority) and improved patient safety within a healthcare organisation. The evidence is so convincing that the US National Patient Safety Foundation (NPSF) lists leadership support for a safety culture as the most important of eight recommendations for achieving patient safety. This overview from the Emergency Care Research Institute (ECRI) provides guidance and recommendations on how to embed approaches to safety culture within healthcare organisations.
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Content ArticleThis is the response submitted by the Patients Association to the Department of Health and Social Care as part of its consultation seeking views on the proposed legislative details on the appointment and operation of the Patient Safety Commissioner for England. In this they argue for arrangements for the Commissioner's appointment and operation to guarantee their independence as securely as possible, and express disappointment that the role will not cover all aspects of patient safety.
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In this blog Patient Safety Learning outlines the key points included in its response to the consultation on establishing a Patient Safety Commissioner for England. This sets out their feedback to this consultation and describes the powers and resources this role will require if it is to effectively influence change and improve patient safety. -
Content ArticleThis article discusses red rules, a safety practice used by industries and are associated only with processes that can cause serious harm to employees, customers, or the product line. The article describes red rule criteria, examples in industry, everyday life, in healthcare and when they are misused, concluding that if appropriately implemented, red rules can have the potential to promote an organizational culture of safety that shares accountability for the safe delivery of patient care.
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Content ArticleIn this article, Andrew Ottaway discusses the five primary components (Just Culture, Reporting Culture, Flexible Culture, Learning Culture and Challenging Culture) that forms a safety-conscious, informed and engaged organisation that is able and willing to deliver an effective Safety Management System.
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Content ArticleThis article considers the definition of a just culture and identifies the key elements associated with this. It then goes on to discuss tools and resources that may be beneficial for leaders who are seeking to create a just culture for staff safety in the perioperative setting.
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Content ArticleIn this blog, published on the Learning from Excellence website, author AP introduces the philosophical theory of determinism and the implications for patient safety investigations.
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In this blog Patient Safety Learning outlines the key points included in its response to the consultation on a proposed Patient Safety Commissioner role for Scotland. This sets out their feedback to this consultation and describes the powers and resources this role will require if it is to effectively influence change and improve patient safety. -
Content ArticleThe NHS is in the process of changing the way it embraces patient safety, moving from a focus on individual incidents and issues to a more comprehensive look at system learning. The changes are set out in NHS England/Improvement’s Patient Safety Strategy, released in July 2019 and updated in February 2021. This was followed by the Patient Safety Investigation Framework in March 2020, due for full implementation by Spring 2022. They are important not just in relation to incident management but also because of the implications they have for strategy and board responsibilities in relation to patient safety. So they need careful attention at all levels of NHS organisations. This article from the Good Governance Institute highlights the safety roles and responsibilities of organisations and moving to a proactive approach to safety management.
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Safety culture discussion cards (Eurocontrol)
Patient Safety Learning posted an article in Good practice
Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. These cards from Eurocontrol are designed to help us to do this. -
Content ArticleRead how Mersey Care NHS Foundation Trust has adopted and embedded its just and learning culture and its training package. The trust estimates that the just and learning culture has provided economic benefits of roughly £2.5million since 2016. A just and learning culture is one focused on fairness and learning, and absent of blame when things go wrong. It aims to encourage staff to feel able to speak up.
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The problem with policies – a blog by Lynne Williams
Lynne Williams posted an article in Improving patient safety
How can we turn the good intentions of a policy into a working model that people use? How can we ensure policies are translated into real, practical solutions? In this blog, Lynne Williams discusses why effective policy implementation is as crucial and important as the content and why we need to look at policies as a collaborative project, headed up by Governance, but written in partnership with the staff that use them to ensure we provide consistent, safe care. -
Content ArticleA concept called “psychological safety” is especially crucial to a team’s success, according to Amy Edmondson, professor of leadership and management at the Harvard Business School. Psychological safety describes “a workplace where one feels that one’s voice is welcome with bad news, questions, concerns, half-baked ideas and even mistakes,” Edmondson tells CNBC Make It. People should feel like they can ask questions, raise concerns and pitch ideas without undue repercussions. This article gives a good introduction to what psychological safety is and how to achieve it in the work place.
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Content ArticleThis Health Service Journal (HSJ) article explores how executive leaders can drive improvement by focusing on developing an organisational culture, building up staff in an open, just, and empowering environment, thereby enabling organisations to meet the challenges of the new and uncertain healthcare environment.
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Flight Safety Foundation: Just Culture Manifesto
Patient Safety Learning posted an article in Culture
“Just Culture” is a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated. Organisations are run by people. In tens of industries – transportation, healthcare, energy, internet, and more – thousands of occupations, and millions of organisations around the world, it is people who make sure that things normally go well. And they nearly always do. But sometimes, things go wrong. Despite our best efforts, incidents, accidents and other unwanted events happen. Following such events, there is a need for support and fairness for those involved and affected, and learning for organisations, industry and society as whole. In the absence of intentional wrongdoing or gross negligence, these obligations should not be threatened by adverse responses either by organisations or States. The Flight Safety Foundation outline their Just Culture Manifesto and invite all who support the principles in this Manifesto to join them, and to help make Just Culture a reality in all countries, industries, and occupations. -
Content ArticleAnnie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without a blame and shame approach.
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