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Showing results for tags 'Just Culture'.
Found 210 results
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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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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 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 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 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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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 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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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. -
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Creating a safety culture
Claire Cox posted an article in Other countries and national agencies
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. -
Content ArticleStaff at C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital, Michigan are adopting a new approach to safety. By picking up near misses, close calls, deviation off protocol and investigating each one via a daily huddle, they are able to enable change system wide.
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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 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.
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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 ArticleIn our previous blog we shared some reflections about the recent case of Dr Gawa-Barba and the implications the case has for the promotion of a learning culture in healthcare. In light of the Gawa-Barba case, the Government set up a review to which we have submitted a paper.
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Reflecting on the Bawa-Garba case
PatientSafetyLearning Team posted an article in Legal matters
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. -
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NHS Resolution: Saying sorry leaflet (September 2018)
PatientSafetyLearning Team posted an article in Good practice
Saying sorry meaningfully when things go wrong is vital for everyone involved in an incident, including the patient, their family, carers and the staff that care for them. This leaflet is part of NHS Resolution's work on duty of candour. -
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A reflective account of the culture of fear
Anonymous posted an article in Bullying and fear
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.- Posted
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Content ArticleSteve 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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Content ArticlePresentation from Ben Tipney and Vikki Howarth at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
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Content ArticlePresentation from Dr Devina Halsall, NHS England & NHS Improvement Northwest Region, at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
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Content ArticlePresentation from Dr Cicely Cunningham from the Doctors' Association UK at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
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RCN: A guide to raising concerns
Claire Cox posted an article in Whistle blowing
This resource from the Royal College of Nursing, will support you to raise concerns wherever you work – in the NHS or independent sector – and whether you raise a concern as an individual or as part of a group. -
Content ArticleWhat links the Mercedes Formula One team with Google? What links Team Sky and the aviation industry? What connects James Dyson and David Beckham? According to this book, they are all Black Box Thinkers. Written by Matthew Syed, Black Box Thinking is a new approach to high performance, a means of finding an edge in a complex and fast-changing world.
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Content ArticleFollowing the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019, chaired by Helen Hughes of Patient Safety Learning, I am pleased to share the speaker presentations on the hub. A new London conference has been announced for 29 April 2020. Telephone: 0161 376 9007; Email: info@openforumevents.co.uk for further information.
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