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Showing results for tags 'Organisation / service factors'.
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Content ArticleThe scale of the emergency response to the COVID-19 pandemic has been extraordinary, but what comes next? The King's Fund spoke with people involved in response efforts for disasters from around the world, from the Christchurch earthquakes in New Zealand to the Grenfell Tower fire in London, to understand what the health and care system can learn from the experience of recovery from other disasters as it responds to the pandemic.
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Content ArticleThe COVID-19 pandemic has exacerbated preexisting weaknesses in the global supply chain. Regional assessments by the Food and Drug Administration (FDA), European Medicines Agency (EMA), and independent consultants, have demonstrated various contributory causal factors requiring changes in policy, relationships, and incentives within the dynamic and developing networks. Human factors and ergonomics (HFE) is an approach that encourages sociotechnical systems thinking to optimize the performance of systems that involve human activity. The global supply chain can be considered such a system. However, it has neither been systematically examined from this perspective.
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Content ArticleIt is a time of transition in NHS finance. The planned recovery from years of deficits and debts that plagued parts of the NHS in recent years has been hit by the enormity of the COVID-19 shock. Alongside this planned recovery, the NHS has been moving away from its decades-long journey toward competition between individual organisations and using market-like approaches to improve performance, to a design based on collaboration and improving population health. Before the COVID-19 pandemic, the NHS was working to restore financial health and deliver on fundamental reform; now, it must achieve these objectives with the added challenge of recovering from the damage of COVID-19. In this article, The King's Fund looks at the history of NHS finances over recent years to draw out learning for this new design. It will be important to apply this learning if the system is to avoid the recurrent ‘resets’ to NHS finance that have been necessary but have only provided temporary solutions, and deliver a new approach that is consistent with the wider objectives of collaboration and integration.
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Content ArticleOrganisation-wide improvement in health care is an important element of the provision of patient safety. Whereas in the past, capabilities and metrics have tended to drive improvement within the NHS – organisations now need to provide strategies to create the infrastructure and the knowledge required to give high quality care. These strategies lead to effective and successful organisational improvement programmes. Having staff with the right skills and having the right culture within an organisation are also seen as vital when looking at transforming care and embedding quality improvement (QI).
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Content ArticleSerious complications and deaths resulting from maternity care have an everlasting impact on families and loved ones. The families who have contributed to the Ockenden Review want answers to understand the events surrounding their maternity experiences, and their voices to be heard, to prevent recurrence as much as possible. They are concerned by the perception that clinical teams have failed to learn lessons from serious events in the past. The learning of lessons and embedding of meaningful change at The Shrewsbury and Telford Hospital NHS Trust and in maternity care overall is essential both for families involved in this review and those who will access maternity services in the future. After reviewing 250 cases and listening to many more families, this first report identifies themes and recommendations for immediate action and change, both at The Shrewsbury and Telford Hospital NHS Trust and across every maternity service in England.
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Content Article
Care Quality Commission: Choosing a baby scanning service
Patient Safety Learning posted an article in Maternity
Ultrasound scans are important for checking the health of you and your baby. There are different types of scanning service and it's important to understand what each type offers. The Care Quality Commission provides some guidelines. -
Content ArticleThe collapse of healthcare services round the world, the behaviour of some of the “agencies” enforcing quarantining, and high levels of patient harm during the COVID-19 pandemic, undoubtedly warrant a strong response. We need a new agenda for change if we are to address the current threat to patient centred healthcare and patient safety globally. Kawaldip Sehmi, CEO International Alliance of Patient Organizations, summarises the key messages and actions from the 9th biennial Global Patients Congress 2020,
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Content ArticleThis study from Clay-Williams et al., published in the International Journal for Quality in Healthcare, aimed to explore the associations between the organisation-level quality arrangements, improvement and implementation and department-level safety culture and leadership measures across 32 large Australian hospitals. The authors found that the influence of organisation-level quality management systems on clinician safety culture and leadership varied depending on the hospital department, suggesting that whilst there was some consistency on patient safety attitudes and behaviours throughout the organizations, there were also other factors at play.
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Content ArticleThis NHS Improvement document provides trusts consolidating their pathology services with guidance on the clinical governance structure of the consolidated pathology network.
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Content ArticleThese resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
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Content ArticleThe emergence of the SARS-CoV-2 virus led to immediate concerns about the impact of infection on pregnant women. In response to the SARS-CoV-2 pandemic the MBRRACE-UK team instituted rapid notification of maternal deaths associated with SARS-CoV-2, following which notifications of SARS-CoV-2-associated maternal deaths were received in early April 2020. Expedited reviews were conducted into all deaths of women with confirmed or suspected SARS-CoV-2 infection during or up to one year after pregnancy, and any deaths of women who died from mental health-related causes or domestic violence, which might have been influenced by public health measures introduced to control the epidemic such as lockdown. This rapid report aims to identify lessons learned to guide future care and pathway changes in the context of infection transmission and the need for public health and NHS service measures to prevent infection.
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Content ArticleDr Abdulelah Alhawsawi, Abdominal Organs Transplant and Hepato-biliary Surgeon, and Director General of the Saudi Patient Safety Center, discusses why hospitals are falling short of safe care levels. He believes healthcare continues to be structurally weak when it comes to the safety conditions and suggests that there is an urgent need for a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. In his essay, Dr Alhawsawi proposes four practical solutions.
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Content ArticleDrawing on a 2010 analysis of the reform and costs of adult social care commissioned by Downing Street and the UK Department of Health, this paper from Glasby et al., published in the Journal of Social Policy, sets out projected future costs under different reform scenarios, reviews what happened in practice from 2010-19, explores the impact of the growing gap between need and funding, and explores the relationship between future spending and economic growth. It identifies a ‘lost decade’ in which policy makers failed to act on the warnings which they received in 2010, draws attention to the disproportionate impact of cuts on older people (compared to services for people of working age) and calls for urgent action before the current system becomes unsustainable.
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Content ArticleThis report from the Action against Medical Accidents (AvMA), authored by Dr David Cousins, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients. The report identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System. The report recommends a number of urgent actions to address these risks to patients.
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Content ArticleIncreased concern for patient safety has put the issue at the top of the agenda of practitioners, hospitals, and even governments. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. Yet the discourse is often oversimplified and underdeveloped. Written from a scientific, human factors perspective, Patient Safety: A Human Factors Approach delineates a method that can enlighten and clarify this discourse as well as put us on a better path to correcting the issues.
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Content ArticleIn recent years, there has been an increasing focus on the role of safety culture in preventing incidents such as medication errors and falls. However, research and developments in safety culture has predominantly taken place in hospital settings, with relatively less attention given to establishing a safety culture in care homes. Despite safety culture being accepted as an important quality indicator across all health and social care settings, the understanding of culture within social care settings remains far less developed than within hospitals. It is therefore important that the existing evidence base is gathered and reviewed in order to understand safety culture in care homes.
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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 Article
The ‘C’ word (May 2017)
Claire Cox posted an article in Other countries and national agencies
The ‘c’ word, 'cost' is often used to defend the status quo in patent safety. This article, published by PatientSafe Network, highlights the importance of assessing the financial loss in not introducing the safety intervention. It includes examples on how to overcome barriers like 'we don't have the money for that' when it comes to delivering safer care. After all, the price of safer care is priceless -
Content ArticleThis article, published by Forbes, looks at the airline industry and discusses the value in not only studying what pilots do wrong, but also what they do right. This can be translated into healthcare, we know lots about what has gone wrong in healthcare but not so much about the small, quiet things that go right. 'In aviation safety, it’s like we’ve been trying to learn about marriage by only studying divorce.' Written by Kirsty Kiernan a professor at Embry-Riddle Aeronautical University who teaches and conducts research in unmanned systems and aviation safety.
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Content ArticleIn this blog published in the New York Times, Theresa Brown explains why American healthcare has become one giant workaround. "The nurses were hiding drugs above a ceiling tile in the hospital — not because they were secreting away narcotics, but because the hospital pharmacy was slow, and they didn’t want patients to have to wait." These 'work arounds ' pose a significant patient safety risk. What work around problems do you have in your department? Theresa Brown is a clinical faculty member at the University of Pittsburgh School of Nursing.
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Content ArticleECRI 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.
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Content ArticleThe use of checklists can help to prevent incidents and should be part of a culture of patient safety. This guidance set out by the Royal College of Radiologists highlights key considerations when writing and implementing safety checklists.
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Content Article
CQC case study: outstanding, safe care for all (May 2017)
Claire Cox posted an article in GP and primary care
Inclusion Healthcare, a social enterprise, provides primary medical services for homeless people in Leicester. It was rated outstanding following its CQC inspection in November 2014. CQC inspectors found strong leadership at its heart and a positive culture that ensures patient safety is paramount. In this short film, we hear from service users and staff and find out how they are promoting patient safety. -
Content ArticleThere are a number of fundamental weaknesses in governance around patient safety and the quality of care at Cwm Taf Morgannwg University Health Board, a joint review by Healthcare Inspectorate Wales (HIW) and the Wales Audit Office found. Following well-publicised concerns about maternity services at the Health Board, the joint review examined the organisation’s overall approach to quality governance. It found that whilst there has been a strong focus on financial balance and meeting key targets, less attention has been paid to the overall quality and safety of its services. The report highlights the need for stronger and broader leadership in respect of quality and patient safety and worryingly, points to a culture of fear and blame in some parts of the organisation that has prevented staff from speaking out and raising concerns.
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Content Article
Museum of failure
Claire Cox posted an article in Miscellaneous
Museum of Failure is a collection of failed products and services from around the world. The majority of all innovation projects fail and the museum showcases these failures to provide visitors a fascinating learning experience. Every item provides unique insight into the risky business of innovation.The idea for the museum was born out of frustration. ‘I was so tired of reading and hearing the same boring success stories, they are all alike’ says the museum’s curator, Samuel West. ‘It is in the failures we find the interesting stories that we can learn from.’ Innovation and progress require an acceptance of failure. The museum aims to stimulate discussion about failure and inspire us to have the courage to take meaningful risks.Could we learn from our 'failures' in healthcare in the same way?
