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Showing results for tags 'Just Culture'.
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Content Article
If only...
Patient Safety Learning posted an article in Good practice from other industries
This documentary is about a tragic and avoidable accident which took place during a diver training course in May 2018. As with many adverse events, there were many contributory and causal factors involved. With hindsight, it is easy to spot them, but in real time, they aren't so obvious. Especially, when they happen relatively frequently without any adverse consequences. A remarkable film with many lessons relevant to health care around human behaviour, systems and just culture. -
Community Post
Resetting priorities for Safer Healthcare
Dr Akhil Sangal posted a topic in Leadership for patient safety
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Content Article
AvMA: Just culture
Patient Safety Learning posted an article in Culture
“Just culture” is rightly, a much-used phrase in patient safety and a major theme in the patient safety strategy for England and all the UK countries. However, there is no single definition of ‘just culture’ and most discussion of it is limited to the issue of being fair to healthcare staff. This is vitally important, which is why we advised on and endorsed the NHS Resolution Being Fair guidance and NHS Improvement’s Just Culture Guide. However, AvMA and many of the stakeholders believe that we need a nationally agreed definition that places equal emphasis on being fair to patients and families, and which covers the whole system, from policy formulation to the delivery of healthcare and what happens when harm occurs. -
Content ArticleStrengthening a safety culture necessitates interventions that simultaneously enable, enact and elaborate in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The Bundle is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture. The Patient Safety Culture "Bundle" for CEOs and Senior Leaders encompasses key concepts of safety science, implementation science, just culture, psychological safety, staff safety/health, patient and family engagement, disruptive behavior, high reliability/resilience, patient safety measurement, frontline leadership, physician leadership, staff engagement, teamwork/communication, and industry-wide standardisation/alignment.
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Content ArticleSafety and improvement efforts in healthcare education and practice are often limited by inadequate attention to human factors/ergonomics (HFE) principles and methods. Integration of HFE theory and approaches within undergraduate curricula, postgraduate training and healthcare improvement programmes will enhance both the performance of care systems (productivity, safety, efficiency, quality) and the well-being (experiences, joy, satisfaction, health and safety) of all the people (patients, staff, visitors) interacting with these systems. Patient safety and quality improvement education/training are embedded to some extent in most curricula, providing a potential conduit to integrate HFE concepts. To support this, Bowie et al. in this article published in Medical Teacher offer professional guidance as “tips” for educators on fundamental HFE systems and design approaches. The goal is to further enhance the effectiveness of safety and improvement work in frontline healthcare practice.
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Content ArticleThe PRAISe project tests the hypothesis that, together, positive reporting and appreciative inquiry can be used as an intervention to facilitate behavioural change and improvement in the related areas of sepsis management and antimicrobial stewardship.
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News ArticleThe former police chief who investigated mental health services in a crisis-hit health board was “shocked” by the poor working relationships and “blame shifting” he uncovered. David Strang, who led the independent inquiry into the issues in NHS Tayside, said staff felt isolated and unsupported and people complained about each other’s practices without coming together to sort the issues out. He described asking staff questions based on information he had received and being met with the response: “Who told you?” He added: “A lot of staff felt there was a real blame culture and that risk and blame fell to the front line.” Read full story (paywalled) Source: 6 February 2020, The Times
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Content ArticleHow people are treated following their involvement in a workplace accident can have far reaching implications for both the individual and the organisation. This paper, published by Science Direct, examines the impact the use of retributive justice mechanisms within the accident analysis process have on both the individual and the organisation. It analyses the perceptions of those involved in five accidents where retributive justice mechanisms were used. The study of these cases shows retributive justice mechanisms used as part of the accident analysis process negatively impacts three key areas; (1) the mental health of the individual; (2) organisational learning and; (3) organisational performance. The study also illustrates that the language used as part of the accident analysis has a significant impact upon the perception of the process and the willingness to participate.
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Community Post
Restorative justice: can we use it in healthcare to repair harm?
PatientSafetyLearning Team posted a topic in Culture
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Restorative justice brings those harmed by crime or conflict and those responsible for the harm into communication, enabling everyone affected by a particular incident to play a part in repairing the harm and finding a positive way forward. This is part of a wider field called restorative practice. Restorative practice can be used anywhere to prevent conflict, build relationships and repair harm by enabling people to communicate effectively and positively. This approach is increasingly being used in schools, children’s services, workplaces, hospitals, communities and the criminal justice system. What are your thoughts on how this approach would work in a healthcare setting? Does anyone have any experience of using restorative practice?- Posted
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Community Post
National Patient Safety Syllabus
Jon Holt posted a topic in Professionalising patient safety
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The Academy of Medical Royal Colleges have published the first National patient safety syllabus that will underpin the development of curricula for all NHS staff as part of the NHS Patient Safety Strategy: https://www.pslhub.org/learn/professionalising-patient-safety/training/staff-clinical/national-patient-safety-syllabus-open-for-comment-r1399/ Via the above link you can access a ‘key points’ document which provides some of the context for the syllabus and answers to some frequently asked questions. AOMRC are inviting key stakeholders to review this iteration of the syllabus (1.0) and provide feedback via completing the online survey or e-mailing Rose Jarvis before 28 February 2020. I would be interested to hear people's thoughts and feedback and any comments which people are happy to share which they've submitted via the online survey- Posted
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Content Article
Creating a just culture
Claire Cox posted an article in Techniques
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. -
Content ArticleSpeaking at the Domain Driven Design conference in 2018, Sidney Dekker talks about the complexity of pursuing and averting drift into failure.
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Content ArticleElisabeth 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.
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Content Article
Blog: Working together to create a more just culture in the NHS
Claire Cox posted an article in Second victim
This blog written by Frankie Hill, a Matron undertaking a secondment in clinical leadership, and Sarah De-Biase, Improvement Associate with the Improvement Academy, discusses the impact on staff when something goes wrong in healthcare. A just and learning culture is the balance of fairness, justice, learning and taking responsibility for actions. -
Content ArticleThis study, published in the BMJ Open, aims to examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and midwives.
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Content ArticleThis paper, published by Science Daily, highlights how a multidisciplinary group of leaders established consensus-driven research agenda designed to create a path forward to inform approaches that better support harmed patients and families.
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Content Article
Apologies and medical error (October 2008)
PatientSafetyLearning Team posted an article in Research
Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologise. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologising after medical error, the author of this article, published in Clinical Orthopaedics and Related Research, argues that the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologising for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error. -
Content ArticleAll healthcare professionals have a duty of candour – a professional responsibility to be honest with patients when things go wrong. This is described in 'The professional duty of candour', which introduces this guidance and forms part of a joint statement from eight regulators of healthcare professionals in the UK. This guidance from the Nursing and Midwifery Council complements the joint statement from the healthcare regulators and gives more information about how to follow the duty of candour principles.
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Content ArticleThis 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.
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Content ArticleA just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong. How do you respond to the people involved? What do you do to minimise the negative impact, and maximise learning? This edition of Sidney Dekker’s extremely successful Just Culture offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety reporting and honest disclosure, about retributive just culture and about the decriminalisation of human error.
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Community PostI am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
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Content ArticleSuzette Woodward is a Senior Advisor for the Department of Health and Social Care and NHS Resolution. She is one of the authors of Being fair: Supporting a just and learning culture for patients and staff following incidents in the NHS. These slides and accompanying commentary give an idea of the content of the report and it’s purpose.
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Content ArticleAt the second annual Patient Safety Learning conference we interviewed Douglas Findlay. Patient Leader at the Royal Berkshire NHS Trust, Douglas discussed why culture is important for patient safety, why it so hard to change the culture of an organisation and what we can do to help make culture better for patients and staff.
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Content ArticleWhat makes an outstanding hospital? is part of the Priory's Better Together podcast series. In this episode, Priory’s Director of Quality for Healthcare, Natasha Sloman, is joined by Professor Sir Mike Richards, former CQC Chief Inspector of Hospitals, and Paul Pritchard, one of Priory’s Managing Directors. They talk about what makes an ‘outstanding’ hospital and Priory’s approach to enabling ‘outstanding’ services.’
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Content ArticleAlberta Health Services (AHS) is Canada’s first and largest province-wide, fully-integrated health system, responsible for delivering health services to the more than 4.3 million people living in Alberta, as well as to some residents of Saskatchewan, B.C. and the Northwest Territories.
