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Showing results for tags 'Organisation / service factors'.
Found 1,519 results
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Content ArticleRather than being a static property of hospitals and other healthcare facilities, safety is dynamic and often on short time scales. In the past most healthcare delivery systems were loosely coupled—that is, activities and conditions in one part of the system had only limited effect on those elsewhere. Loose coupling allowed the system to buffer many conditions such as short term surges in demand. Modern management techniques and information systems have allowed facilities to reduce inefficiencies in operation. One side effect is the loss of buffers that previously accommodated demand surges. As a result, situations occur in which activities in one area of the hospital become critically dependent on seemingly insignificant events in seemingly distant areas. This tight coupling condition is called “going solid”. Rasmussen’s dynamic model of risk and safety can be used to formulate a model of patient safety dynamics that includes “going solid” and its consequences. Because the model addresses the dynamic aspects of safety, it is particularly suited to understanding current conditions in modern healthcare delivery and the way these conditions may lead to accidents.
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Content ArticleBrighton and Sussex University Hospitals NHS Trust found a key challenge in tackling emergency department (ED) doctors' low levels of satisfaction, high rates of burnout and high turnover was because of the way shifts were organised. They found that while ED could be a highly pressurised environment that could contribute to these issues, another key challenge was the way shifts were organised and the lack of flexibility that had become a standard part of being an ED doctor.
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Content Article
Far Beyond the Pale
Claire Cox posted an article in By patients and public
The preventable death of Connor Sparrowhawk in July 2013 led to a number of investigations and enquiries into practice at Southern Health NHS Foundation Trust in whose care he died. -
Content ArticleFrom this Windmill 2009 simulation event, and discussions with policy-makers, regulators, commissioners and providers, managers and clinicians, an analysis was developed of what will be required if health and social care systems are to respond effectively to the major challenges that lie ahead. It identifies key themes and recommendations for action in each of these.
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Content Article
The Betsy Lehman Center
Patient Safety Learning posted an article in International patient safety
The Betsy Lehman Center is a Massachusetts state agency that supports providers, patients and policymakers working together to advance the safety and quality of health care. -
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 Article
PSNet: Systems Approach
Claire Cox posted an article in In health care
The Patient Safety Network (PSNet) discuss a case of a 65 year old who went in for one operation, but ended up having a completely different operation. -
Content ArticleSir Stephen Moss, Patient Safety Learning Trustee, is the former Chairman of Mid Staffordshire Hospitals NHS Trust, following their damming Healthcare Commission report of 2009. In this interview with Patient Safety Learning, Sir Stephen tells us about lessons learnt and what more needs to be achieved to make the NHS one of the safest healthcare systems in the world. View video (15 minutes)
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Content ArticleThe Safer Nursing Care Tool has been developed by the Shelford Group to help NHS hospital staff measure patient acuity and/or dependency to inform evidence-based decision making on staffing and workforce. The tool, when allied to Nurse Sensitive Indicators (NSIs), offers nurses a reliable method against which to deliver evidence-based workforce plans to support existing services or to develop new services. The Shelford Group is an organisation comprising Chief Executives of 10 of the leading NHS multi-specialty academic healthcare organisations in England. The Chief Nurses of each of these NHS Trusts belong to a subgroup of the organisation and they meet every two months to share best-practice, benchmark and work towards improving standards in nursing.
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Content ArticlePatient Safety Learning speaks to Ben Tipney, Managing Director of MedLed and the hub topic lead in Human Factors, about how healthcare can achieve high performance and learn from other industries, including from the sports industry.
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Content Article
Safer staffing - guidance from NHS Improvement
Patient Safety Learning posted an article in Safe staffing levels
NHS Improvement provide general guidance and a starting point towards delivering effective safer staffing. -
Content ArticleNHS England helps illustrate the benefits of business continuity planning and how the planning is implemented during a response. Case studies have been put together from various incident debrief reports from organisations to provide examples of approaches to incident reports and also allow identification of learning across organisations
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Content ArticleHuman Factors Cast is a podcast that investigates the sciences of psychology, engineering, biomechanics, industrial design, physiology and anthropometry and how it affects our interaction with technology. Hosted by Nick Roome and Blake Arnsdorff.
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Content ArticleThe London Maternity Strategic Clinical Network (SCN), in collaboration with Nutshell Communications and hospitals in the London region, has delivered a number of "Whose Shoes?" user experience workshops for healthcare professionals, commissioners and users, to explore local concerns, challenges and opportunities, focusing on service improvement. This document provides 11 case studies which illustrate some of the outcomes from the trusts who have to date taken part in the workshops.
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Content ArticleSacha Wells-Munro, Maternity Improvement Advisor at NHS Improvement and Professor Tim Draycott, consultant obstetrician and Health Foundation Improvement Science Fellow, present at the Patient Safety Learning Conference the lessons learned from the Morecambe Bay maternity scandal and changes needed to improve the safety of maternity services system wide.
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Content ArticleAlthough debate continues over estimates of the amount of preventable medical harm that occurs in healthcare, there seems to be a consensus that healthcare is not as safe and reliable as it might be. It is often assumed that copying and adapting the success stories of nonmedical industries, such as civil aviation and nuclear power, will make medicine as safe as these industries. However, the solution is not that simple. This article explains why a benchmarking approach to safety in high-risk industries is needed to help translate lessons so that they are usable and long lasting in healthcare. Five successive systemic barriers currently prevent health care from becoming an ultrasafe industrial system: the need to limit the discretion of workers, the need to reduce worker autonomy, the need to make the transition from a craftsmanship mindset to that of equivalent actors, the need for system-level (senior leadership) arbitration to optimise safety strategies, and the need for simplification. Finally, healthcare must overcome 3 unique problems: a wide range of risk among medical specialties, difficulty in defining medical error, and various structural constraints (such as public demand, teaching role, and chronic shortage of staff). Without such a framework to guide development, ongoing efforts to improve safety by adopting the safety strategies of other industries may yield reduced dividends. Rapid progress is possible only if the health care industry is willing to address these structural constraints needed to overcome the 5 barriers to ultrasafe performance.
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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.
