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Showing results for tags 'Organisational learning'.
Found 543 results
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Content ArticleThe Piper Alpha exploded and sank on 6 July 1988, killing 165 of the men on board. Some of the lessons learned from the inquiry into the Piper Alpha Disaster could be applied to healthcare.
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Content ArticleQuality improvement and patient safety have been important topics on the agenda in the Danish health care system for >20 years. Over the years, Denmark has developed an array of national quality and patient safety initiatives. This paper aims to describe how quality improvement and patient safety initiatives have been organised in the Danish health care system and highlight how accountability has been achieved.
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Content ArticleThe Institute for Healthcare Improvement (IHI)-convened National Steering Committee for Patient Safety (NSC) has released a National Action Plan intended to provide US health systems with renewed momentum and clearer direction for eliminating preventable medical harm. Safer Together: A National Action Plan to Advance Patient Safety draws from evidence-based practices, widely known and effective interventions, exemplar case examples and newer innovations. The plan is the work of 27 influential federal agencies, safety organisations and experts, and patient and family advocates. The plan provides clear direction that health care leaders, delivery organisations, and associations can use to make significant advances toward safer care and reduced harm across the continuum of care.
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Content ArticleMersey Care NHS Foundation Trust is committed to delivering perfect care but this depends on the development of a just and learning culture.
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Eric Kutscher: First, do no harm—but did I?
Patient Safety Learning posted an article in Blogs
The cost of providing care during a pandemic is seeing firsthand the evolution of medical knowledge, and wishing current data could have guided past decisions, says Eric Kutscher in this BMJ Opinion article. -
Content ArticleSorrel King was a 32-year-old mother of four when her eighteen-month-old daughter, Josie, was horribly burned by water from a faulty water heater in the family's new Baltimore home. She was taken to Johns Hopkins--renowned as one of the best hospitals in the world--and Sorrel stayed in the hospital with Josie day-in and day-out until she had almost completely recovered. Just before her discharge, however, she was erroneously injected with methadone, and died soon after. Sorrel's account of her unlikely path from grieving parent to nationally renowned advocate is interwoven with descriptions of her and her family's slow but steady road to recovery, and ends with a deeply affecting description of a ski trip they took recently. The sun is shining, her children are healthy, and they are all profoundly happy--a condition that Sorrel has learned to appreciate all the more for Josie. The book ends with a resource guide for patients, their families, and healthcare providers; it includes information about how to best manage a hospital stay and how to handle a medical error if one does occur.
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Content ArticleDr Abdulelah Alhawsawi, Abdominal Organs Transplant and Hepato-biliary Surgeon, and Director General of the Saudi Patient Safety Center, discusses why hospitals are falling short of safe care levels. He believes healthcare continues to be structurally weak when it comes to the safety conditions and suggests that there is an urgent need for a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. In his essay, Dr Alhawsawi proposes four practical solutions.
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Content ArticleNeil Spenceley is a paediatric intensivist and is the National Lead for Paediatric Patient Safety. This talk is packed with nuggets that will change the way you view the world in which you practice. Neil explains Safety 1 and Safety 2 thinking. The talk is wide-ranging and covers poor behaviours in healthcare both at a personal level and at an institutional level. This talk was recorded live at Don't Forget the Bubbles 2019 in London, England.
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Content ArticleIt has been 20 years since the report An Organisation With A Memory drew attention to the problem of adverse health events in the NHS. Since then, patient safety has blossomed as an explicit policy focus of the NHS (and other health systems worldwide), bringing with it new regulatory and organisational arrangements, safety campaigns, reporting and alerting systems, and other measures intended to enshrine patient safety at the heart of health care. At this juncture, it is useful to reflect on developments over the past few decades. The following timeline has been put together by myself, historian Christopher Sirrs, as part of the Wellcome Trust project 'Hazardous Hospitals: Cultures of Safety in NHS General Hospitals, c.1960-Present.' Members of the Patient Safety Learning hub are invited to comment or reflect on the timeline, highlighting innovative safety campaigns, research projects, or other initiatives which have promoted patient safety in the UK. More broadly, the project is interested to hear from anyone with direct experience of promoting safety in NHS hospitals, such as patient safety managers, clinical risk managers, or members of official bodies. Further details can be found on the project website.
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Content ArticleIn this article Patient Safety Learning responds to a recent news story about an Ambulance Service reviewing their defibrillators after receiving two warnings from Coroners Prevention of Future Deaths reports. It considers the specific circumstances around this and how this case highlights a broader problem of failing to harness learning from these coroners reports for patient safety.
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NHS England Learning Handbook: After action review
Patient Safety Learning posted an article in NHS Improvement
First used by the US army on combat missions, the after action review is a structured approach for reflecting on the work of a group and identifying strengths, weaknesses and areas for improvement. This NHS Improvement document explains what an after action review and when and how to use it. -
Content ArticleWhat can we take from the steady flow of Prevention of Future Deaths Reports (PFDs) issued by coroners in relation to patient care? How do these fit into the wider learning from deaths landscape? To help answer these questions, international law business DAC Beachcroft have taken a closer look at hospital-related PFDs to see if any common themes emerge and, if so, what is in the pipeline for tackling them.
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Is doing nothing, doing no harm?
Dr Mark Lomax posted an article in How to engage for patient safety
Dr Mark Lomax, CEO of PEP Health, the social listening tool of patients, talks about the lack of discussion following the “First Do No Harm” Cumberlege Report and why patient safety and experience should be viewed differently. -
Content ArticleThis paper, from THIS Institute, aims to describe exactly what needs to happen for maternity care to be safe by examining how interventions and context work together to nurture and sustain safe practice.
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Content ArticleGroup B streptococcus (GBS) is a naturally occurring bacterium, often found in the mother’s vagina, which can be dangerous for babies during labour and immediately after birth. The mothers carry this bacterium in the birth canal without any problem to themselves. Giving antibiotics to the mother during labour reduces the incidence of GBS infection passing on to the baby (National Institute for Health and Care Excellence, 2012).
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Content ArticleThe Framework sets out a single set of standards for staff to follow and provides standards for leaders to help them capture and act on the learning from complaints. This is a draft Framework developed with partners across the health sector and PHSO are keen to hear people's views on the draft so they can improve it. The online survey can be found here.
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To boldly go: Leadership amid crisis
lzipperer posted an article in Letter from America
This month’s Letter from America looks at actions and strategies core to leading an organisation during unexpected enterprise-affecting crises. Letter from America is the latest in a Patient Safety Learning blog series highlighting new accomplishments in patient safety from the United States. -
Content ArticleThe purpose of this guide from the Chartered Institute of Ergonomics and Human Factors (CIEHF) 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 COVID-19 pandemic has suddenly challenged many healthcare systems. To respond to the crisis, these systems have had to reorganise instantly, with little time to reflect on the roles to assign to their patient safety (PS) and quality improvement (QI) experts. In many cases, staff who had a background in clinical care was called to support wards and critical care. Others were deemed “non-essential” and sent back to work from home, while their programmes were placed in hibernation mode. This has meant that many QI and PS experts with skills to offer in their field have ended up carrying out tasks unrelated to the current crisis.
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Content ArticleThe Chartered Institute of Ergonomics & Human Factors has issued today their White Paper on Adverse Events. This report states what good practice should be in incident investigation across all industries, including health and social care. The White Paper is designed to: 1. Help organisations understand a human factors perspective to investigating and learning from adverse events. 2. Provide key principles organisations can apply to capture the human contribution to adverse events. How organisations learn, and fail to learn, from adverse events is discussed.
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The right – and duty – of NHS staff to speak up
Hugh Wilkins posted an article in Whistle blowing
A blog from hub topic lead Hugh Wilkins on the recent messages from NHS England and NHS Improvement leaders reminding everyone, including those at board level, of the duty and right of staff to speak up about anything which gets in the way of patient care and their own wellbeing. Hugh highlights the real risk of reprisals against some staff who have raised concerns in the public interest, and points out that much needs to change before NHS staff can be sure that it is safe for them to speak up.- Posted
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Content ArticleReport from the Saudi Patient Safety Center on: 1. Hospital Survey on Patient Safety Culture National Recommendations Cycle 2: (2019), and 2. National Supplementary Recommendations related to COVID-19.
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Content ArticleA 14 minute TEDx talk by Niall Downey, a doctor and pilot, exploring how healthcare could modify aviation's approach to error for use in managing and reducing adverse events to improve patient safety.
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Content ArticleAviation underwent a major culture change after the shock of the 1977 Tenerife disaster, which has gradually matured into the successful safety management systems we have today. Has the Hyponatraemia Report in Northern Ireland or the Bawa-Garba case in the UK the potential to be healthcare's turning point and transform our approach to error? What can we learn from aviation to shortcut the learning process? The author of this article is both a doctor and pilot with extensive experience in both industries. Published in Northern Ireland Healthcare Review in 2018.
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Content ArticleI wrote this editorial for the Journal of Surgical Simulation after delivering the keynote talk at the Homerton Hospital, London Surgical Simulation conference in 2018. It outlines how aviation approaches error and its use of simulation in training to deal with it safely and efficiently. Aviation Safety Management Framework and the extensive use of simulation is a safe, value for money tool.
