Search the hub
Showing results for tags 'Organisational learning'.
Found 540 results
-
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.
-
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.
-
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.
-
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.
- Posted
- 2 comments
-
1
-
- (and 4 more)
-
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.
-
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).
-
Content ArticleAlexander James Davidson was aged 17 years and 6 months when he died at the Queens Medical Centre on 26 February 2018. Alex was previously fit and well before suddenly taking ill with abdominal pain on 17 January 2018. Between that date and his admission to the Queens Medical Centre on 8 February 2018, Alex made contact with his GP on three occasions, had four telephone triage assessments undertaken by the NHS 111 service and two admissions to his local Accident & Emergency Department at the Kingsmill Hospital. Alex’s symptoms of sudden onset acute abdominal pain, tachycardia, and vomiting and diarrhoea were attributed either to stress or to a bout of gastroenteritis. At no stage prior to 8 February 2018 was gallstones or pancreatitis considered as a differential diagnosis. When Alex was eventually admitted to the Queens Medical Centre Emergency Department on 8 February 2018, he was found to be septic as a result of an infected and necrotic pancreatic pseudocyst, which had evolved as a complication of gallstone pancreatitis, a rare condition in someone of Alex’s age. Despite medical intervention, Alex did not survive. The inquest explored the medical treatment and intervention that Alex received in the six weeks prior to his death. The medical evidence concluded that the pancreatic pseudocyst had likely formed by the time Alex began vomiting on 18 January 2018, and from that point onwards, it was unlikely he would survive even with treatment on account of the high mortality rate associated with this condition
-
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.
-
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.
-
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. -
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.
-
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.
-
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.
-
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.
-
Content Article
Can being open and transparent make us more opaque?
Anonymous posted an article in Florence in the Machine
‘Neo’ is an Allied Health Professional working on the frontline and asks what being open and transparent actually means and whether publishing a report or an investigation is just another tick box exercise if lessons aren't learned. -
Content ArticleThe Safety Engineering Initiative for Patient Safety (SEIPS) is arguably the best known and most published systems-based Human Factors framework in healthcare worldwide. Developed by Professor Pascale Carayon and colleagues in the University of Wisconsin, the SEIPS framework is partly based on Donabedian’s well-known Structure-Process-Outcome model of healthcare quality. SEIPS is strongly grounded in a Human Factors based systems approach.
-
Content ArticleIn this webinar, MISHC Research Fellow Philippa Dodshon analyses research into practitioners’ experiences with incident investigation to determine how they can be used to enhance organisational learning and reduce the prospect of repeat accidents.
-
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.
-
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.
-
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 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.
-
Content ArticleIn July 2015 five NHS Trusts were selected to work with Virginia Mason Institute (VMI) to develop localised versions of the Virginia Mason Production System (an adaption of the Toyota Production System, a continuous improvement approach commonly known as Lean). The goal was to develop a sustainable culture of continuous improvement capability in each of the five partner NHS hospital Trusts, and to share lessons from the partnership with NHS system leaders. Here are a series of video interviews with the CEOs of these NHS Trusts and the Virginia Mason Institute.
-
Content ArticleInsight into medical device and system failure and the teachings of Henry Petroski, a professor of civil engineering at Duke University, who wrote about failure analysis and design theory.
-
Content ArticleThe Ockenden review into the failings in maternity care at Shrewsbury and Telford Hospital NHS Trust in the UK makes for sobering reading. The review focuses predominantly on the period from 2000 to 2019 and estimates that there were significant or major concerns in the care of nine women and more than 200 babies who died while receiving care at the Trust. Many more women and babies suffered serious injuries. It was clear that the Shrewsbury and Telford Hospital NHS Trust did not investigate, learn, change, or listen to families when adverse events occurred. The conclusions of the Ockenden review make it clear that safe staffing levels, a well trained workforce, an ability to learn from incidents, and a willingness and ability to listen to families are all crucial for safe maternity care.
-
Content ArticlePEOPLE FIRST is a CQC resource to help system leaders and service providers.
