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Showing results for tags 'Organisational learning'.
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Content ArticleEarly in the pandemic, neither the NHS’s clinical or ancillary staff nor social care workers were adequately protected from the risks of catching covid-19 in the course of their work. In the UK alone, hundreds of infected workers have died, thousands have been admitted to hospital, and tens of thousands have experienced long term effects, How do we improve staff protection next time? Here’s David Oliver's manifesto.
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Content ArticleIn this Editorial for the journal Midwifery, maternity experts come together to respond to the Ockenden review and discuss what went wrong and what needs to happen now.
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Content ArticleSurgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. In an article in the June issue (page 16), Patient Safety Learning's Helen Hughes describes the steps being taken to address the widescale issue of avoidable harm.
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Content ArticleThe purpose of the Learn from patient safety events (LFPSE) service (previously known during development as the Patient Safety Incident Management System - PSIMS) is to enable learning from patient safety events – incidents, risks, outcomes of concern and also things that went well. Our ability to protect future patients from harm depends on promoting a culture that welcomes and encourages the recording of events. It is essential to abide by these principles to ensure that we continue to successfully learn from patient safety events and reduce harm. This document sets out the circumstances in which LFPSE data are the appropriate data source to be used and describes their appropriate use. These principles emphasise the purpose and characteristics of LFPSE data, and promote consistency across data users. It is essential that users of LFPSE data understand and represent it appropriately, as inappropriate presentations of LFPSE data could discourage recording.
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Content ArticleWhen something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what the Care Quality Commission (CQC) and the provider have done about it, and the steps you can take to avoid it happening in your service.
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Content ArticleIn March 2017 the National Quality Board issued the guidance on the actions all NHS Trusts should undertake to learn from a review of the care provided to patients who die stating it should be integral to a provider’s clinical governance and quality improvement work. Hertfordshire Partnership University Foundation Trust have developed a policy on Learning from Deaths setting out the work to be undertaken to review care provided to service users who die in the Trust's care.
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Content ArticleThe Improvement Analytics Unit (IAU) was set up in 2016 as an innovative partnership between the Health Foundation and NHS England and NHS Improvement. It was tasked with evaluating the impact of some of the major new initiatives in health care in order to support learning and improvement in the NHS. Arne Wolters is Head of the IAU, leading a team of analysts across the Health Foundation and NHS England and NHS Improvement. Together they work on detailed evaluation studies and provide rapid feedback to NHS leaders and decision makers, helping to identify what’s working well to improve outcomes. Here Arne discusses what the unit has achieved over the last 6 years, and what new plans are forming for the future.
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Content ArticleThis study, published in the Journal of the Royal Society of Medicine, examines national policies of complaint handling in English hospitals, how they are understood by those responsible for enacting them, and explores if there are any discrepancies between policies-as-intended and their reality in local practice.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Bill talks to us about how patient safety and transparency have been key priorities throughout his career as an Operating Department Practitioner (ODP) and then a leader in the NHS. He highlights the need for a longer-term approach to workforce planning and talks about how leaders can set a culture that engages with and prioritises patients. -
EventThis national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework). NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version with the revised framework due in Spring 2022. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review. This conference will enable you to: Network with colleagues who are working to improve the investigation of serious incidents and deaths in mental health services. Ensure your approach to Serious Incident Investigation is in line with the Patient Safety Incident Response Framework (PSIRF). Learn from outstanding practice in implementing the Royal College of Psychiatrists Mortality Care Review Tool. Reflect on the lived experience of a bereaved relative. Improve the way you involve and engage families and carers in the investigation process. Develop your skills in incident investigation and mortality review. Understand how you can improve serious incident investigation and learn from Mental Health early adopters of the New Patient Safety Incident Response Framework. Identify key strategies for undertaking a self assessment, and continuous review of deaths and investigation practice in your organisation. Understand how human factors can help improve learning from serious incident investigation. Ensure you are up to date with the role of the coroner. Understand how you can better support staff when a serious incident occurs. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register
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Content ArticleThis study from McQueen et al. explored what ‘good’ patient and family involvement in healthcare adverse event reviews may involve. Nineteen interviews were conducted with patients who had experienced an adverse event during the provision of their healthcare or their family member.
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Content ArticlePresentation slides from NHS England and NHS Improvement's Tracey Herlihey, Head of Patient Safety Incident Response Policy, Lauren Mosley, Head of Patient Safety Implementation and Matthew Fogarty, Associate Director of Patient Safety (Policy and Strategy) on the Patient Safety Incident Response Framework (PSIRF).
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Content ArticleThe NHS Patient Safety Strategy was published in 2019 and describes the Patient Safety Incident Response Framework (PSIRF), a replacement for the NHS Serious Incident Framework. This document is North Bristol NHS Trust's Patient Safety Incident Response Plan (PSIRP). It describes what North Bristol NHS Trust did to prepare for “go live” with PSIRF, as an early adopter organisation, and what comes next
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Content ArticleTeri Price has been on a pretty steep learning curve since her husband Greg’s death. She (like many people) made a lot of assumptions about the healthcare system. She assumed that every possible action to make care safe would be undertaken and that healthcare providers worked in a supportive, collaborative environment where they could focus on their patients. Over the last couple of months, leading up to today, Teri has been reflecting on what has happened in the last ten years and what we have learned.
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Content ArticleThis practice pointer in The BMJ explains why diagnostic errors occur and provides five strategies that healthcare workers can use to achieve diagnostic excellence. Each of these strategies is explored in detail: Seek diagnostic feedback, which includes tracking patient outcomes and seeking feedback from patients, families and other healthcare workers. "Byte sized" learning, which involves digital learning activities. Consider bias by getting to know patients and treating them as individuals, and through taking a 'diagnostic pause' to consider whether bias is playing into decisions. Make diagnosis a team sport through multidisciplinary huddles that include healthcare workers from different professions. Foster critical thinking by using intentional strategies to foster reflective scepticism and regular review.
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Content ArticleOne box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable – does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture.
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Content Article"Shaming and punishing healthcare workers when an incident occurs sets a dangerous precedent for the industry. This will lead to a culture where healthcare workers avoid reporting near misses or errors for fear of repercussions, allowing process inefficiencies and systemic problems to occur." In this letter, Michael Ramsay, CEO of the Patient Safety Movement Foundation, highlights the negative ways in which criminalising healthcare workers who make mistakes will affect patient safety. He refers to the case of RaDonda Vaught, a nurse who was convicted of criminally negligent manslaughter in March 2022 for a medication error made while working at Vanderbilt University Medical Center in Nashville.
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Content Article‘Digital clinical safety’ refers to avoiding harm to patients and staff that could be caused by technologies manufactured, implemented and used in the health service. In this blog, Dr Kelsey Flott, Deputy Director of Patient Safety at the NHS Transformation Directorate, looks at the importance of digital clinical safety in driving quality improvement. She talks about how the Digital Clinical Strategy is being implemented and the drive to collect better evidence about the effectiveness of improvement technologies.
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Content ArticleThis study in the journal Health and Social Care Delivery Research mapped interventions aimed at reducing restrictive practices in children and young people’s institutional settings around the world. It also assessed which process elements led promising behaviour change techniques, and compared the results with a companion review of adult psychiatric inpatient settings. In the first evidence review of its kind, the authors found that interventions tend to be complex, reporting is inconsistent and robust evaluation data are limited. But they did find some behaviour change techniques that warrant further research. They argue that better evidence could help address the urgent need for effective strategies.
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Content ArticleThis report has been developed by the Patient Coalition for AI, Data and Digital Tech in Health, which aims to unite representatives from patient advocacy groups, including Patient Safety Learning, Royal Colleges, medical charities, industry and other stakeholders committed to ensuring that patient interests lie at the heart of digital health policy and discussions. The report focuses on how programmes have worked with patients to reduce digital health inequalities, by supporting those who are unable to access and use the internet and digital devices to improve their health and general wellbeing.
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Content Article
Safety Chats blog series: Part 1
Gina Winter-Bates posted an article in Good practice
In a series of blogs, Gina Winter-Bates, Associate Nurse Director Quality and Safety at Solent NHS Trust, shares her experience of implementing Safety Chats. In this first blog, Gina explains what motivated her to introduce Safety Chats into her Trust. -
Content Article"The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC.
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Content ArticleMaternity services shouldn’t be waiting for whistle-blowers or inquiries to alert them to problems, says Dr Mark Ratnarajah, a practising paediatrician and managing director of C2-Ai. Instead systematic transdisciplinary reviews and real-time data should support a culture of shared learning, that helps ensure patient safety is everybody’s responsibility.
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Content ArticleIn this letter nine charities and patient organisations write to Sajid Javid MP, Secretary of State for Health and Social Care, urging him to reconsider plans to impose fixed costs on lower value clinical negligence claims. They argue that the proposals are a threat to both access to justice and patient safety.
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Content ArticleThe UK Government has announce a statutory public inquiry into the handling of the Covid-19 pandemic - the Hallett inquiry. However, in light of the wide-ranging impact of the pandemic, the inquiry faces a huge task to decide on the highest priority areas for investigation. This long read by Tim Gardner, Senior Policy Fellow at The Health Foundation, aims to examine what the parameters and structure of the UK Covid-19 Inquiry could be, and set out what it might realistically cover.
