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A few years back, I was a guest speaker at a healthcare quality improvement conference where I was approached by a doctor who said he had come to learn “what all this patient safety stuff is about". He had approached me after my presentation and, with more than a little arrogance in the tone of his voice, stated, “if only the nurses would do their jobs and follow my orders correctly, all of these errors would simply go away!” Hmmm…, a damaged and lost soul! My first reaction was to wonder what kind of slimy rock this chap had crawled out from under. However, rather than get annoyed, an emotion that rarely results in improved communication, I simply mentioned that the most current analysis of injuries resulting from patient safety incidents has revealed that the majority of serious injuries, malpractice claims and settlements result from errors or delays in diagnosis and that, the last time I checked, clinical diagnosis is primarily the purview of doctors not nurses. I figured he might want to continue the conversation, but he simply turned and walked away. The truth hurts and I was left wondering how many patients he had harmed, knowingly or unknowingly, during his career. Blaming others can be an easy out from self-examination. As I thought about this interaction later that evening, putting his insulting arrogance aside, it occurred to me that his complacency about his role as a contributor to the patient safety conundrum, and the challenges of assuring diagnostic accuracy specifically, is probably much more common than many would like to admit. Fortunately, his degree of professional arrogance is generally not the rule among compassionate professionals. Still, there is something to learn from his arrogance and from what he said. Complacency, subtle, unrecognised and perhaps pernicious, can become a malignant force. We are all prone to this. We all know that caring for patients, especially for vulnerable patients, is fraught with hazards. We work in highly complex environments, interacting with innumerable patients and professionals every day, each of whom brings strengths and liabilities into the equation we call healthcare. We all acknowledge that there are deficiencies in the structures and processes of healthcare systems and these numerous deficiencies can contribute to patient harm. Anyone who has spent time working in healthcare settings can point to examples of poor leadership, unsafe and unjust cultures, demand-based management and flawed or inadequate healthcare processes that may adversely affect the provision of care and can degrade professional morale. We have all been there. Well-documented deficiencies in the structures and processes of healthcare certainly encumber those working to actually provide care. Frontline staff working under pressure can and will make mistakes; even in institutions where robust efforts have been made to support staff and specifically improve the working environment on the frontlines, mistakes will still occur. Human beings make mistakes, and even though our processes can be standardised to reduce variability and enhance ease of performance, mistakes still will occur, especially in the domain of diagnostic accuracy where standardisation is not so robust and cognitive insufficiencies and biases abound. Caring for patients is complicated stuff! Healthcare professionals do not get up in the morning intending to harm anyone, but normal human liabilities can impair our performance. Often we do not even recognise our own liabilities or are unaware of the environmental factors that can enhance them. Workplace complexities and associated stressors such as fatigue, hunger, patient volume and acuity complexity can all contribute to distractions in an already task-saturated environment. If we also factor in outside family, social and economic pressures of various kinds, which we rarely leave at home entirely, the stage is often set for mistakes to occur, sometimes very serious mistakes. The aviation industry is an example of a highly reliable industry where safety is paramount and is often held up as a standard of performance to strive for in healthcare. But an A&E unit is a much more complex and relatively uncontrolled environment than the flight deck of an Airbus 320. In my view, the aviation metaphor commonly falls short when compared to healthcare. As a physician who has also worked in the aviation community for part of my career, I feel that although important lessons can be learned and shared from the aviation industry, the aviation environment is not a mirror image of the healthcare environment. Anyone out there ever made a mistake when caring for a patient? I have made many, I suspect, most unknown to me and of little or no consequence to my patients. I did make a more serious mistake once and my patient, a 9-month-old child, was dangerously but not permanently harmed. When oncologists make mistakes, the consequences can be catastrophic as chemotherapy agents are dangerous. The truth is, I was complacent and didn’t see the potential for harm coming right at me; my fault – or at least that was how I viewed things. I became a ‘second’ victim as a result of this incident and it still resonates with me, all these years later. Hospitals with strong committed leadership are attempting to address the challenges that those on the frontlines must face every day, especially in settings such as A&E units, but one cannot simply design out all of the confounders. There are some excellent examples of robust, patient and staff-focused leadership, safe and just cultures and collaborative management, and these should be emulated nationwide. This all brings me back to the arrogant doctor who wanted to blame the nurses for “all this patient safety stuff”, and his inherent failure to recognise his own singular, important role in the patient safety conundrum. I suspect that this is a natural tendency, as healthcare professionals do not ordinarily see themselves as sources of harm, a concept that is counterintuitive to who we think we are and the excellence in care we strive to provide. The fact is that we may all suffer from some degree of professional complacency. We may often fail to recognise environmental and situational risks, and, more importantly, to admit to our own personal liabilities, and, thus, the risks we bring into the healthcare environment. Though we all recognise how complex the provision of healthcare can be, we may not fully appreciate that we are also part of that complexity. Our inability to recognise the often subtle but inherent risks we bring to our patients in all healthcare settings is surely an independent variable in the calculus of providing patient safe care. So, I propose the following for all healthcare professionals – each day, before we enter our hospital or surgery, care home or whatever, please pause and repeat the following mantra: “I am a kind and caring professional about to enter a complex healthcare environment where patients may be harmed every day. I admit to myself that although I always intend to serve my patients as best I can, I also inherently represent a source of risk for them and I may make mistakes that can result in harm. Though I may wish to deflect responsibility onto insufficiencies in structures, processes, leadership, culture, managers and even other colleagues, the fact is that I am also a unique risk to my patients. I will be very careful, every day, in every way, with every patient under my care, all the time; and I will strive to be even better tomorrow.” Read Dan's full length article: Structures, processes and outcomes for better or worse: Personal responsibility in patient safe care

This web page includes: What NHSX do How they work Apps and tools for patient care Policies and strategy Blogs and updates

The report argues that better engaged staff have higher morale, make fewer errors and deliver better patient experience. It demonstrates that patients receive more appropriate care and better outcomes when they are actively engaged in their care and highlights how leaders must be increasingly effective at integrating healthcare activities across healthcare systems. It sets out recommendations and outlines the argument for engagement, looking at what engagement means and why it matters. It looks at engaging across the system as well as with specific groups: Staff Patients Doctors Nurses and allied health professionals Boards

Three NHS case studies (from acute care, primary care and commissioning) are described and reviewed in the light of evidence from successful organisational change in the US. Eight key features of successful leadership for patient and family centred care are outlined: Strong, committed senior leadership Active engagement of patients and families Clarity of goals Focus on the workforce Building staff capacity Adequate resourcing of care delivery redesign Performance measurement and feedback

From the 5365 operations, 188 adverse events were recorded. Of these, 106 adverse events (56.4%) were due to human error, of which cognitive error accounted for 99 of 192 human performance deficiencies (51.6%). These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.

Organisational culture is the essential element in meeting healthcare goals, according to Stephen Swensen, Professor Emeritus at the Mayo Clinic College of Medicine and Senior Fellow at the Institute for Healthcare Improvement. “Culture, more than anything else, drives performance,” he says. In that context, it is notable that culture at many healthcare organisations is changing, and in the right direction, say nearly 60% of respondents to the latest NEJM Catalyst Insights Council survey. Three-quarters of respondents (clinical leaders, clinicians, and executives from organisations directly involved in health care delivery) label culture change a high or moderate priority in their organisation.

The paper summarises the literature on the use of simulation with many examples of application in the field of patient safety. It explores the evidence on the impact of simulation. It goes on to suggest four areas where QI and simulation practitioners interested in closer integration of their fields might focused: Read - add articles found in quality/safety or simulation journals that integrate both fields onto your reading list. Study - seek out professional development opportunities: courses, workshops, conferences in QI methodology or simulation/debriefing. Collaborate - identify individuals in your local institution and find ways to work (and research) together. Engage - connect with the larger community of practice working on these topics via in-person meetings or platforms such as Twitter and LinkedIn.

We know from our own experiences and those of others that patient safety fears are growing daily across the NHS and social care. Staff shortages and burnout are all taking their toll on patient satisfaction, safety and standards of care. I had the pleasure of joining a webinar arranged by the Health Foundation last week where the National Director of Improvement for NHS England and NHS Improvement, Hugh McCaughey, outlined the up and coming improvement framework for the NHS. A good framework provides a skeleton on which to build. His presentation included the importance of: leadership both at the Board and at the front line people who are empowered and engaged a culture built on collaboration and continuous improvement, where it’s safe to learn co-production – engagement, empowerment and ‘lived experience’. Workshops, seminars and conversations across social media will follow in 2020 to build the thinking. So, be ready to contribute and help make sure patient safety is coming through as the top priority. And as you do, keep a copy of Roy Lilley’s latest blog in your hand. For those who don’t follow him, Roy is a health policy analyst, writer, broadcaster and commentator on the NHS and social issues. He recently posted this summary, outlining NHS electoral promises. Please do as he suggests – pin this up and bring it out every time you see a politician and whenever you have the opportunity. This way we can all ensure that these promises will be delivered.

The content covers six characteristics fundamental to a healthy culture: Inspiring vision and values Goals and performance Support and compassion Learning and innovation Effective teamwork Collective leadership.

This guide includes: analysis of the key concepts in spreading ideas evidence on what is known about what works to spread improvement practical suggestions for planning communications, engaging the right people, sustaining interest in the work and celebrating and sharing achievements.

The Quality Accounts FAQs on how to produce and publish your Quality Account, including: who to share your Quality Account with how to publish your organisation's Quality Account how to access the indicator data through the NHS Digital indicator portal the technical definitions of indicators and the dates when specific data sets are available, including the Quality Accounts Data Dictionary Quality Accounts audit guidance Quality Accounts reporting arrangements.

This report features practical solutions from staff. Frontline clinicians attended workshops to help highlight the issues and identify what needs to change to keep services safe when facing surges in demand.

The book blends literature on the nature of practice with diverse and eclectic reflections from experience in a range of contexts, from healthcare to agriculture. It explores what helps and what hinders the achievement of the core goals of human factors and ergonomics (HF/E): improved system performance and human wellbeing. The book should be of interest to current HF/E practitioners, future HF/E practitioners, allied practitioners, HF/E advocates and ambassadors, researchers, policy makers and regulators, and clients of HF/E services and products.

Drawing on a dizzying array of case studies and real-world examples, together with cutting-edge research on marginal gains, creativity and grit, Matthew Syed tells the inside story of how success really happens - and how we cannot grow unless we are prepared to learn from our mistakes.

Healthcare safety is complex every day – yet the emergence of the novel coronavirus has made holes in the Swiss cheese of the system more apparent. UK psychologist James Reason’s now famous “Swiss Cheese Model” serves as a metaphor for this month’s Letter from America. As more details on the coronavirus emerge, and time enables reflection on what has transpired, deeper analyses will no doubt materialise. Knowledge is developing in real time, helping us see gaps in our safety barriers and providing valuable insight to the challenge of reducing harm. The Swiss Cheese model illustrates how latent weaknesses in the protective barriers that systems build exist and become more apparent after failures occur – if we look for them. COVID-19 is just such a test; it is amplifying the holes in today’s healthcare system. A recent New Yorker essay highlights the known weaknesses in healthcare visible long before COVID-19 – racial inequities, bureaucratic inefficiencies, drug shortages, under resourced public health initiatives and fiscal prioritisation to the detriment of preparedness. Others are more specific to the pandemic: lack of access to personal protective equipment and medical devices, supply chain disruptions, hording behaviours, misinformation and patients not seeking chronic, emergency or preventive care. The essay suggests that we should not seek to return to this “normal”, but to learn, revise and improve. Holes in processes to keep patients and workers safe are also expanding as the cheese melts. Healthcare worker illness, psychological strain and suicide are revealing fractures across US healthcare delivery that undermine the ability of clinicians to provide care as they work to keep patients and themselves safe. The US National Academies of Medicine has outlined an approach to protect clinicians’ wellbeing. Through a focus on organisational and national priorities, it aims to help sideline the negative after-effects that first responders to the COVID-19 crisis may experience through a call for funding, epidemiology and real-time support for providers. Efforts to diagnose COVID-19 are thick slices of cheese with a myriad of holes that affect both clinical and policy responses. As summarised in a recent commentary, the system response is a fundamental challenge: measurement is a mess, data are inconclusive, testing processes are inconsistent and results in some cases unreliable. While this state of affairs is rapidly changing, foundational concerns are likely to remain. Economic support for organisations and States rests on the data that are apt to be skewed, ineffective and counterproductive. The international disease codes used to document COVID-19 cases are being imprecisely applied. The authors of the commentary provide suggestions to impove the use of the diagnostic codes and thus the quality of the data collected. Actions in this area are needed to inform the research so we can understand what has happened and fund and design public health initiatives and reopening strategies that enable containment, testing and equitable treatment. As time passes, suggestions for improvement informed by national and local experience appear. Communities are painfully aware of the situation COVID-19 places them in. Experts there are contextually situated to address local challenges such as population instability due to unemployment, homelessness and food insecurity. A Health Affairs blog calls for strengthening the community-based workforce to assist in propping up vulnerable populations after disaster of any kind strikes, including COVID-19. Community health workers, volunteers and nonprofit organisations are highlighted as important players in testing and contact tracing strategy implementation, psychological support provision and establishment of the infrastructure communities need to face their specific challenges. It will take resources, tenacity and courage to facilitate and sustain community level COVID-19 response. Watching media coverage can be overwhelming but can also illustrate the complexity of addressing the disruptive tendencies of the coronavirus pandemic. Newspapers and healthcare media services can provide insight into the system-level complexity of the pandemic. These services are flagging and providing access to articles from the press or literature to provide a well-rounded collection of materials to track what is happening. It’s one way to remain keep abreast of the issues: who from racial, ethnic and socioeconomic groups are impacted, what programmes and industries are being altered, where specifically in the US the virus touches, when the threat emerged to affect a particular segment of the population or workforce and why the connections between them all are important to consider. This is highlighted in a recent commentary in the Lancet, which illustrated some of the interacting components in a society responding to the threat of COVID. Tools such as these can assist in keeping us informed to combat weaknesses in failure barriers that emerge due to bias from listening to one outlet or seeking only one point of view. No matter what slice of the COVID-19 Swiss cheese sits on the plate in front of us – its holes are apparent. Experts are calling for coordinated system-wide action to prevent further loss of life and economic hardships. Other challenges are likely to emerge the longer COVID-19 influences lives. We all need to learn from the lack of success during the current response manifestation and use those insights to inform actions to prepare for the next virus wave. It will help to navigate future choppy, uncharted waters. To prepare for the 'new normal', courage to see value in failure is paramount. We should also proactively apply learnings based on what went well to better prepare organisations, systems and governments to close holes in the global approach before the next wave.

These guides include: Surgical patients Othopaedics Critical care Endocrinology Trauma Acute General medical Burns Cancer ED Paediatrics NIV Rheumatology Management of COVID positive patients Cardiothoracics plastics Max Fax Vascular Spinal Surgery Radiology Cardiology Muscular Skeletal Haematology Maternity TB.

The Leapfrog Group is a US nonprofit organisation 'driving a movement for giant leaps forward in the quality and safety of American healthcare.' Their flagship Leapfrog Hospital Survey collects and transparently reports hospital performance to inform purchasers and giving consumers information to make informed decisions. The Leapfrog Hospital Safety Grade, Leapfrog’s other main initiative, assigns letter grades to hospitals based on their record of patient safety. Safety In Numbers summarises findings from the 2018 Leapfrog Hospital Survey, submitted by over 2,000 hospitals nationwide. This is the first year Leapfrog reported the new surgical standard by hospital, assessing whether both hospitals and surgeons met volume standards, and whether hospitals monitored for surgical necessity. This Leapfrog report states that patients should be very careful before they choose a hospital for one of these high-risk procedures and should worry even more about hospitals that decline to report this information because 'candour and transparency is the necessary first step to improvement.'

The report describes key messages from the review in relation to leadership at different levels of analysis: it includes a description of the leadership task and the most effective leadership behaviours at individual, team, board and national levels.

17 minute video of Don Berwicks presentation.