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Found 1,089 results
  1. Content Article
    In most cases pregnancy and birth are a positive and safe experience for women and their families. This is the outcome that everyone working in maternity services wants every time, for every woman. But when things go wrong, we need to understand what happened, and whether the outcome could have been different. The death or injury of a new baby or mother is devastating and something that everyone working in the health and care system has a responsibility to do all they can to prevent. Following the publication of ‘Getting safer faster’ the Care Quality Commission (CQC) launched a programme of risk-based, focused maternity safety inspections involving a more focused in-depth assessment of relational elements such as teamworking and culture, staff and patient experience. Building on our previous calls for action, the CQC also sought to further explore the barriers that prevent some services from providing consistently good, safe care and to better understand the disparities in outcomes that exist for women and babies from Black and minority ethnic groups. This report presents the key themes from nine of those inspections alongside insight gathered from direct engagement with organisations representing women using maternity services and their families, including Five X More and local Maternity Voices Partnerships.
  2. Content Article
    This paper discusses the use of safety culture assessment as a tool for improving patient safety. It describes the characteristics of culture assessment tools currently available and discusses their current and potential uses, including brief examples from healthcare organisations that have used them. It also highlights critical processes that healthcare organisations need to consider when deciding to use these tools. The authors highlight safety culture assessment as the starting point for patient safety changes. They suggest that safety culture assessment is useful if it: involves key stakeholders uses a suitable safety culture assessment tool uses effective data collection procedures implements action planning and initiates change.
  3. Content Article
    It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."
  4. Content Article
    The NHS Staff Survey for England reported that almost a quarter of all NHS staff experienced harassment, bullying or abuse from colleagues in the last 12 months. Not only does this have a devastating impact on individuals and the teams within which they work, but it can have dire consequences for patient care. The Royal College of Surgeons of Edinburgh is committed to eradicating bullying and undermining from the surgical and dental professions. It has a number of resources on its website.
  5. Content Article
    In this video, Helen Hughes, Chief Executive of Patient Safety Learning, speaks to Phil Taylor, Chief Product Officer at RLDatix, about the importance of culture in achieving high reliability in healthcare. They discuss the impact of culture on incident reporting, examples of where safety culture is key to making improvements and consider what is needed to create the right safety culture.
  6. Content Article
    Hospitals across the US are grappling with nurse shortages as the pandemic continues to change the healthcare system as we know it. Two intensive care unit nurses who left their jobs shared their experiences in Becker's Hospital Review.
  7. Content Article
    This blog is the introduction to a joint series of blogs and video conversations exploring how we can improve patient safety through the application of principles of high reliability in healthcare, made collaboratively by Patient Safety Learning and RLDatix.
  8. Content Article
    Although many initiatives have been implemented and great strides have been achieved in improving patient safety and reducing preventable medical errors, progress towards achieving "zero" avoidable harm continues to be slow. This video presentation will address common medical errors, their recognition, potential for harm and the psychological and financial costs. The concepts of human factors, system design and the high reliability organisation will be reviewed. New approaches in reducing harm and restoring trust will be described along with the opportunity for physician leadership.
  9. Content Article
    Establishing a culture of zero harm is critical for organizations that strive to deliver safe, high quality, patient-centered care. This video features insights from leading organisations—Advocate Health Care, Cancer Treatment Centers of America, Boston Children’s Hospital, Novant Health, and MedStar Health—that have embraced a commitment to making safety a core value. Watch now to learn how they overcame the challenges of building a highly reliable safety culture and benefited from making safety and high reliability a top priority within their organisations.
  10. Content Article
    Hundreds of healthcare organisations around the world are Schwartz Center healthcare members and conduct Schwartz Rounds® to bring doctors, nurses and other caregivers together to discuss the social and emotional side of caring for patients and families. This video explains more.
  11. Content Article
    Attached is a list of research papers on Schwartz rounds that you might find useful.
  12. Content Article
    Providing high quality healthcare has an emotional impact on staff. Often they experience high levels of psychological distress, face increasing levels of scrutiny, regulation and demand, and have increasingly limited resources. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff deliver compassionate care by providing a safe space where staff could openly share and reflect on the emotional, social and ethical challenges of their work. Rounds are a monthly staff forum (not attended by patients) where three to four employees (panellists) present short accounts of their experiences of delivering patient care. This organisational guide is based upon the findings from an evaluation of Rounds in the UK, undertaken between 2014 and 2016. The evaluation was commissioned by the National Institute for Health Research and led by Professor Jill Maben at King’s College London (now at the University of Surrey). The evaluation aimed to distil the findings and learning for practical application by organisations seeking to implement and/or sustain Rounds in their organisations.
  13. Content Article
    Shabazz et al. explore incidents of bullying and undermining among obstetrics and gynaecology consultants in the UK, to add another dimension to previous research and assist in providing a more holistic understanding of the problem in medicine.
  14. Content Article
    Amy Edmondson, the Novartis Professor of Leadership and Management at Harvard Business School, talks about building a psychological safe workplace for staff in this TEDx talk.
  15. Content Article
    When employees share novel ideas and bring up concerns or problems, organisations innovate and perform better. But managers do not always promote employees’ ideas. In fact, they can even actively disregard employee concerns and act in ways that discourage employees from speaking up at all. While much current research suggests that managers are frequently stuck in their own ways of working and identify so strongly with the status quo that they are fearful of listening to contrary input from below, new research offers an alternative perspective: managers fail to create speak-up cultures not because they are self-focused or egotistical, but because their organisations put them in impossible positions. They face two distinct hurdles: they are not empowered to act on input from below, and they feel compelled to adopt a short-term outlook to work.
  16. Content Article
    “We have to create the culture of learning; the culture of having a safe space, the culture of wanting to do better and learning those conditions in which we do do better” This powerful talk looks directly at how a clear approach to patient safety really can improve the standard of care where you work. What is the culture of quality and safety that you’re trying to embed, can you actually do better? Learn why it’s important to focus on psychological safety; “if people start being scared, everyone gets scared then it expands”. Learn how an evidence based approach can allow us to tackle these issues rather than shy away from them; “what factors are maintaining safety? How do we get to good outcomes? What are the things working well? How do we understand human variation?”. Presented by Lee Fleisher, Emeritus Professor of Anesthesiology and Critical Care, University of Pennsylvania.
  17. Content Article
    This rapid review from the BC Patient Safety & Quality Council provides an overview of the role of culture in healthcare settings, including the common limitations and best practices related to the measurement of culture. The review also highlights selected survey instruments, including a description of what is measured by each survey and their relative strengths. No one survey instrument is identified as the gold standard to measure culture in a health care setting. This literature review offers guidance and supports the use of survey tools to generate discussion, provide data for comparison and foster improvement to culture within organisations.
  18. Content Article
    Visual representation from Steven Shorrock on a quick way to evaluate where you can improve the flows of reporting within your organisation. The red highlights stronger influences.
  19. Content Article
    In healthcare, leadership is decisive in influencing the quality of care and the performance of hospitals. How staff are treated significantly influences care provision and organisational performance so understanding how leaders can help ensure staff are cared for, valued, supported and respected is important. Research suggests ‘inclusion’ is a critical part of the answer, as Roger Kline explains further in this BMJ Opinion article.
  20. Content Article
    Disagreements are an inevitable, normal, and healthy part of relating to other people. There is no such thing as a conflict-free work environment. Amy Gallo explains why disagreements — when managed well — have lots of positive outcomes.
  21. Content Article
    The aim of this study from Björklund et al. was to describe factors that contribute to the occurrence of workplace bullying, that enable it to continue and the coping strategies managers use when they are bullied.  They found that several factors could be linked to the bullying: being new in the managerial position; lack of clarity about roles and expectations; taking over a work group with ongoing conflicts; reorganisations. The bullying usually lasted for quite some time. Factors that allowed the bullying to continue were passive bystanders and the bullies receiving support from higher management. The managers in this study adopted a variety of problem-focused and emotion-focused coping strategies. However, in the end most chose to leave the organisation.
  22. Content Article
    The Essentials of Safe Care is a practical package of evidence-based guidance and support that enables Scotland’s health and social care system to deliver safe care.
  23. Content Article
    Presentation from Terry Wilcutt Chief, Safety and Mission Assurance, and Hal Bell Deputy Chief, Safety and Mission Assurance at NASA.
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