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Showing results for tags 'Organisational learning'.
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Content ArticleThe Serenity Integrated Mentoring (SIM) model is described as "an innovative mental health workforce transformation model that brings together the police and community mental health services, in order to better support 'high intensity users' of Section 136 of the Mental Health Act (MHA) and public services." The SIM model is part of a 'High Intensity Network' (HIN) approach, which is now live in all south London boroughs. In this hub post, Steve Turner highlights the benefits and risks of this approach and seek your views on it.
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Content ArticleThe COVID-19 pandemic has profoundly impacted the country’s health systems and diminished its capability to provide safe and effective healthcare. This article from Sharda Narwal and Susmit Jain attempts to review patients safety issues during COVID-19 pandemic in India, and derive lessons from national and international experiences to inform policy actions for building a ‘resilient health system’
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Content Article
In his latest blog, Ehi Iden, hub topic lead for Occupational Health and Safety, OSHAfrica, discusses the importance of documenting and learning from patient safety incidences. Using a fictional story to draw parallels from, Ehi highlights how accountability, leadership and reporting incidences will help us keep staff and patients safe. -
Content ArticleThis first webinar of Global Patient Safety Webinar Series 2021 introducing the “WHO Patient Safety Incident Reporting and Learning Systems: Technical report and guidance” which was released on 17 September 2020 on World Patient Safety Day. The webinar presented an overview of the technical guidance, and the country experiences on implementing and managing the patient safety incident reporting and learning systems. A recording of the webinar is available below.
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Content ArticleThis is the coroners report into the death of Brandon-Robert, who was born on 29 May 2020, and died of E. coli sepsis a week later.
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Content ArticleVisual 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.
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Content ArticleThis policy aims to set out for the first time for the NHS the core aims and values of the LeDeR programme and the expectations placed on different parts of the health and social care system in delivering the programme from June 2021.
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Content ArticleThe focus on error detection and its management has not produced the expected gains in patient safety, primarily because these methods are not well suited to a complex adaptive system such as healthcare. Behaviours that produce errors are variations on the same processes that produce success, so focusing on successful practices may be a more effective tactic. One approach to focusing on success is positive deviance. While positive deviance can be used to describe the behaviour of an exemplary individual, the term can also be extended to describe the behaviours of successful teams and organisations. Originating in international public health projects, positive deviance has recently been embraced to improve quality and safety of healthcare delivered in organisations. The premise is that solutions to common problems mostly exist within clinical communities rather than externally with policy makers or managers, and that identifiable members of a community have tacit knowledge and wisdom that can be generalised. Lawton et al. explain more in this BMJ article.
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Content ArticleThe purpose of this guide from NHS Education for Scotland is to help people working in the health and social care ecosystem capture valuable practice and improvements made during their response to COVID-19. The aim is to contribute to organisational change at a policy, strategic and operational level. If left too late, there is a real danger that positive change is not documented and will be lost as the health system emerges from the pandemic.
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Content ArticleThe precautionary principle is important in high risk, high harm, safety critical work. Risks to workers, customers, or service users are substantial, and so the precautionary principle in which precautions are taken until safety is proven, often apply. However, in healthcare it’s different. Healthcare takes the approach that the status quo applies until something is proven dangerous and harmful. The burden of proof is often high and often falls to the workforce to “prove.” Alison Leary, Professor of healthcare and workforce modelling at London South Bank University, in this BMJ article discusses the reasons healthcare fails to heed the precautionary principle and why potentially the cost of doing so is high and ultimately catastrophic.
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News Article
Hospitals failing to heed warnings over patient deaths, reveals new study
Patient Safety Learning posted a news article in News
Thousands of similar errors contributing to patient deaths are being repeated by hospitals despite warnings from coroners, according to new research. An analysis of four years of official reports by coroners, issued after the conclusion of inquests into patient deaths, has revealed the impact of the NHS struggling with a lack of resources and staff. Coroners found similar mistakes across hundreds of inquests. Professor Alison Leary, chair of healthcare a workforce modelling at London South Bank University, and who led the study, told The Independent: “We are missing opportunities to prevent deaths. What we are seeing is the hard edge of underinvestment in the workforce and the under resourcing of the service. “Each of these coroner’s reports are someone’s sorrow. From talking to families, they assume when one of these reports is issued, they are acted on and the system learns from it. But the system doesn’t seem to be learning and people pay for this with their life.” Read full story Source: The Independent, 3 March 2021 -
Content ArticleThe Coroners and Justice Act allows coroners in England or Wales to issue reports after inquest, if they believe that action should be taken to prevent a future death. Coroners are under a statutory duty to issue a Prevention of Future Death (PFD) report to persons or organisations that they believe have the power to act. Cumulatively, these reports may contain useful intelligence for patient safety.
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Content ArticleWith the National Learning from Deaths Programme Board stalled, the bereaved families who were to be involved in its work have once again been left harmed and without any answers, write Dr Josephine Ocloo and David Smith in this HSJ article.
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Content ArticlePrevention of Future Deaths Reports (PFDs) made by coroners to address concerns arising from inquests can provide powerful leverage for change, although the reality is that health and social care organisations would generally rather avoid a PFD if possible because they also highlight - in a very public way - concerns about how their services operate which can, in turn, lead to further regulatory scrutiny, principally from the CQC. The need for more consistency in terms of thresholds for making PFDs and the form these take, plus the Chief Coroner’s strong commitment to ensuring that PFDs do what they are designed to do - i.e. harness learning from deaths - have been key drivers behind a recent re-vamping of the existing Chief Coroner’s guidance note on this. What do health and social care organisations need to know about the revised PFD guidance? This briefing looks in more detail about what’s changed (and what hasn’t).
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Content Article
Patient referrals and waiting lists: A ticking time bomb
Jerome P posted an article in By health and care staff
Jerome, a patient safety manager, discusses the impact the pandemic is having on patient referrals and waiting lists, and the subsequent increases in serious incidents and never events that will arise. With an already overstretched and exhausted workforce, how will these be investigated, how will this be managed? Jerome urges NHS England to give guidance.- Posted
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Content Article
Ergonomics to support the COVID-19 response
Patient Safety Learning posted an article in Process improvement
Without embedded experience within healthcare organisations the application, evidence and business case for human factors in NHS decision-making will not be developed. The concerns about availability of ventilators offered the first opportunity to support the NHS. A rapid response project was initiated to support the design, development, usability testing and operation of new ventilators. This article from the Chartered Institute of Ergonomics & Human Factors looks at their response to the rapidly manufactured ventilators and their five-step approach response that was used to influence both strategy and practice to address concerns about changing safety standards and the detailed design procedure with ventilator manufacturers. It also discusses organisational learning and achieving sustainable change and the next steps in patient safety. -
Content ArticleIn March 2020, the Healthcare Safety Investigation Branch (HSIB) published a national learning report to highlight the themes emerging from the initial investigations carried out as part of their maternity investigation programme. These initial investigations were carried out between April 2018 and December 2019. One of these themes was babies significantly larger than average who were at increased risk of a birth injury, brain damage or very rarely death because their shoulders get stuck during birth (known as shoulder dystocia). This was identified as an area where further analysis could benefit system-wide learning.
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Content Article
Why isn’t After Action Review used more widely in the NHS?
Judy Walker posted an article in Barriers
After Action Review (AAR) is a tried and tested, evidence-based approach that increases learning after events but, despite the clear benefits to patient safety and team resilience, its use in the NHS is still more limited than it should be. Judy Walker explains three of the barriers seen in clinical settings. -
Content Article
Learning from excellence in healthcare
Patient Safety Learning posted an article in Implementation of improvements
Learning from everyday work means learning from all activities regardless of the outcome. But when things go well, this is typically just gratefully accepted, without further investigation. ‘Learning from Excellence’ is changing this, as Adrian Plunkett and Emma Plunkett describe in this article. -
Content Article
The problem with policies – a blog by Lynne Williams
Lynne Williams posted an article in Improving patient safety
How can we turn the good intentions of a policy into a working model that people use? How can we ensure policies are translated into real, practical solutions? In this blog, Lynne Williams discusses why effective policy implementation is as crucial and important as the content and why we need to look at policies as a collaborative project, headed up by Governance, but written in partnership with the staff that use them to ensure we provide consistent, safe care. -
Content ArticleA conversation with John Wilkes (AstraZeneca), Clifford Berry (Takeda), Amy D. Wilson, Ph.D. (Biogen), and Jim Morris (NSF Health Sciences). This article is the first part of a two-part roundtable Q&A focused on human performance in pharmaceutical operations. Part 1 discusses key drivers for human performance improvement, compares lean manufacturing and human performance programmes, and provides perspectives on human performance in the context of the rapid scale-up and production of COVID-19 therapeutics and vaccines. Part 2 reviews human performance in the context of company investigation and CAPA programmes.
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Content ArticleSue Hignett and Paul Bowie propose taking a much-needed professional approach to patient safety through an accredited learning pathway to integrate safety into clinical systems and develop healthcare safety specialists and experts
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Content ArticleA conversation with John Wilkes (AstraZeneca), Clifford Berry (Takeda), Amy D. Wilson, Ph.D. (Biogen), and Jim Morris (NSF Health Sciences). This article is the second part of a two-part roundtable Q&A on the topic of human performance in pharmaceutical operations. Part 1 evaluated the underpinnings of human performance and provided advice to those individuals managing rapid production scale-up to support COVID-19 production demand. Here in Part 2, human performance in the context of investigation and CAPA programmes is considered.
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Content ArticleThe Serious Incident framework describes the process and procedures to help ensure serious incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again. This framework explains the responsibilities involved when dealing with serious incidents and includes actions staff are required to take, and the tools available. It is designed to inform staff providing and commissioning NHS funded services in England who may be involved in identifying, investigating or managing a serious incident. It is relevant to all NHS-funded care in the primary, community, secondary and tertiary sectors, including private sector organisations providing NHS-funded services. At some point in 2022, the Serious Incident framework will be replaced by the Patient Safety Incident Response Framework
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Content Article
Why learn from everyday work? (Steven Shorrock, 2020)
Sam posted an article in Improving patient safety
For a few reasons – especially regulatory requirements – the majority of effort when it comes to safety management concerns abnormal and unwanted outcomes, and the work and processes in the run up to these. We need to learn from incidents – for moral, regulatory and practical reasons. But incidents alone don’t tell us enough about the system as a whole. If we view incidents as the tip of the iceberg in terms of total hours of work or total outcomes, then what lies beneath? Steven Shorrock explores this in an article for HindSight.
