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Showing results for tags 'Organisation / service factors'.
Found 1,519 results
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Content ArticleThis infographic, by patient Jennifer Gilroy, demonstrates what makes patients feel safe and what contributes to them feeling unsafe in a hospital environment.
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Content ArticleHealthcare systems are under stress as never before. An ageing population, increasing complexity and comorbidities, continual innovation, the ambition to allow unfettered access to care and the demands on professionals contrast sharply with the limited capacity of healthcare systems and the realities of financial austerity. This tension inevitably brings new and potentially serious hazards for patients and means that the overall quality of care frequently falls short of the standard expected by both patients and professionals. The early ambition of achieving consistently safe and high-quality care for all1 has not been realised and patients continue to be placed at risk. In this paper published in BMJ Quality & Safety, Amalberti and Vincent discuss the strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to.
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Content ArticleA Parliamentary and Health Service Ombudsman (PHSO) report of an investigation that found that Averil Hart's tragic death from anorexia would have been avoided if the NHS had cared for her appropriately. Ignoring the alarms: How NHS eating disorder services are failing patients highlights five areas of focus to improve eating disorder services.
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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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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. -
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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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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 ArticleCOVID-19 is an unprecedented crisis which has had a profound impact on health and care services across the UK and will continue to have an impact for the months and years to come. To guide the restoration of services, 25 cancer charities have come together and developed this document to set out a ‘12-point plan’, supported by available data and intelligence, for what they believe the health service in England will need to do to enable cancer services to recover from the pandemic.
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"I know this is burnout. I didn’t want it to be. But it is."
Claire Cox posted an article in Blogs
I have been honest in my blogs during the pandemic. I have been apprehensive, scared and, at times, excited to work in the pandemic. So why do I feel so low at this moment? I am experiencing feelings that I have not had before. I have thoughts of leaving nursing. Surely, I can’t be the only one? Why now? Why am I feeling like this? This blog is to explore why this might be.- Posted
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Association for Anaesthetists: Tips for night shifts
Claire Cox posted an article in Motivating staff
The Association for Anaesthetists have produced some 'top tips' for night shift workers. What tips do you have to keep you feeling well overnight? -
Content ArticleIt is widely known that prisons in England and Wales are crowded and facing severe difficulties, but the health and health care use of the prisoners within has received little attention. Drawing on over 110,000 patient hospital records for prisoners at 112 prisons, this study from the Nuffield Trust provides the most in-depth look to date at how prisoners’ health needs are being met in hospital.
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James Titcombe: The complexity of failure (2 October 2018)
PatientSafetyLearning Team posted an article in Culture
When James Titcombe is hit by the biggest tragedy imaginable to any parent, he and his wife need to confront a tragedy on a bigger scale still: the structural learning disabilities of the organisation that robbed them of their child. The ‘complexity of failure’ video documents the struggle to get the largest employer of the land to account for what was lost. Behind the bureaucracy and posturing, the lies and denials, it discovers a humanity and a richly facetted suffering by many others. It drives a determined James Titcombe to change how we learn from failure forever. -
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NHS: Specialty guides for patient management
Claire Cox posted an article in Guidance
Speciality guides for patient management during the coronavirus pandemic. -
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COVID-19: Provision of intensive care beds
Claire Cox posted an article in Data, research and statistics
This interview with intensivist and CEO of the the UK Sepsis Trust, Ron Daniels, shown on the Victoria Derbyshire programme, states the '... the UK cannot increase its ICU capacity "rapidly enough" to deal with levels of coronavirus patients'' Fears are growing for the safety of patients who will be contracting the virus, some of who will need intensive care, but there is not enough beds or trained staff to care for them appropriately. -
Content Article'Hospitals should remove any barriers to doctors eating and drinking during the working day'. As healthcare providers, it’s easy to forget to look after ourselves at work. We know that taking breaks and eating and drinking regularly is a critical component of being “optimised,” helping to sustain our energy, concentration and performance, and reduce the risk of human error. Yet, for many, the realities of working in busy, modern hospitals get in the way. Medicine is a demanding profession, with days often starting early and finishing late and many fall into the habit of forgetting to take regular breaks, not drinking enough fluids, or missing meals. If we want to improve staff wellbeing and reduce the risk of errors, we need to change this.
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Designing a safe space for neonatal care
Claire Cox posted an article in Process improvement
As well as designing specific products, ergonomists and human factors specialists can help understand how the space within which we work can be best designed. This can help encourage effective communication in a workplace, as well as considering the comfort of all those present. The Chartered Institute for Ergonomics and Human Factors have come together with stakeholders involved in the care of neonates to design a space that is safe for newborn babies and staff that care for them. -
Content ArticleIn a blog for the Healthcare Financial Management Association (HFMA), Patient Safety Learning’s Chief Executive Helen Hughes highlights both the human and financial costs associated with the persistence of avoidable harm in healthcare. She outlines how Finance directors should play a key role in improving patient safety and argues that they have an essential corporate leadership role to ensure healthcare is both effective and safe.
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Content ArticleMany people will experience mental health problems in their lives. Around one in six adults in England have a common mental health disorder, and around half of mental health problems start by the age of 14. This report from the National Audit Office focuses on the implementation of NHS commitments as set out in the Five Year Forward View for Mental Health, Stepping forward to 2020/21: The mental health workforce plan for England and the the NHS Long Term Plan. It examines whether the government has achieved value for money in its efforts to date to expand and improve NHS-funded mental health services by evaluating whether DHSC, NHSE and other national bodies: have a clear understanding of how much their work to date has reduced the gap between mental and physical health services met ambitions to increase access, capacity, workforce and funding for mental health services are well placed to overcome the risks and challenges, including the impact from COVID-19, to achieving future ambitions.
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Content ArticleLast week, one of the country’s largest child and adolescent mental health services, Forward Thinking Birmingham, run by Birmingham Women’s and Children’s Foundation Trust, was rated “inadequate” by the Care Quality Commission. The inspection report makes for concerning reading — not least because it speaks to a range of issues being experienced by other providers of CAMHS services across the country. CQC inspectors warned there were not enough nursing and support staff to keep people using community services from avoidable harm. Nurses told the CQC that vacancies in the service impacted on people being allocated a care coordinator — and staff were leaving largely due to handling caseloads they felt were unsafe. Part of HSJ’s Mental Health Matters fortnightly briefing, covering safety, quality, performance and finances in the mental health sector.
