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Showing results for tags 'Organisational learning'.
Found 540 results
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Content ArticleSix monthly summaries of how the NHS reviewed and responded to the patient safety issues you reported.
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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 Article
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 ArticleA lack of medical engagement is known to represent a significant barrier to quality improvement within NHS England. In the context of clinical audit, securing medical engagement is critical to its long-term success because it helps to facilitate organisational learning so that the same errors are not subsequently repeated by others. By fostering open cultures medical engagement can help doctors to re-frame error as a learning opportunity. By engaging doctors in this process, clinical audit goes beyond being a tool of quality control by providing a vehicle for continuous improvement in standards of diagnostic reporting. This study from Ross, Hubert and Wong identified the barriers and facilitators of doctors’ engagement with clinical audit and explores how and why these factors influenced doctors’ decisions to engage with the NHS National Clinical Audit Programme. The study documents performance feedback as a key facilitator of medical engagement with clinical audit. It found that medical engagement with clinical audit was associated with reduced levels of professional anxiety and higher levels of perceived self-efficacy.
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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 ArticleWhen it comes to patient safety, a substantial body of evidence exists to demonstrate interventions (leading practices and processes) that lead to improved patient outcomes for numerous healthcare conditions. Despite available evidence, practice changes are not implemented consistently and effectively to support organizations and teams to address patient safety challenges. This resource has been designed by the Canadian Patient Safety Institute to support teams across all healthcare sectors in using a Knowledge Translation and Quality Improvement integrated approach to change that will impact patient safety outcomes. This Guide for Patient Safety Improvement is intended to accompany current best available evidence change ideas, and tools and resources for your specific project. It includes ideal practice changes “the what” and strategies “the how” that creates the evidence-based intervention. Adaptations are expected and important considerations for implementation will be provided in this guide.
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Content ArticleDr Michael Leonard and Dr Allan Frankel explore how effective leadership and organisational fairness are essential for patient safety within healthcare services. They discuss how leaders can influence their organisations to help create a robust safety culture.
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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 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 ArticleThis paper from Helen Hughes presents a proposal to improve the safety of patients and the effectiveness of healthcare using Human Factors methods.
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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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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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Content Article
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 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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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 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 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 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 ArticleDelivering world-class cancer research is at the heart of what they do at The Christie. Developing new treatments to improve outcomes for patients is one of their key priorities. They lead research into innovative techniques such as using DNA to personalise treatment and to help people’s immune systems fight cancer and there are more than 650 clinical research studies and trials running at any given time. The Christie have internationally recognised expertise in cancer research. Their research makes a difference for people living with cancer and their friends and families. Cancer research expertise at The Christie includes: running research studies and trials across all types of cancer delivering the highest quality clinical trials identifying appropriate research participants and involving them in the right research studies providing an excellent service and patient support Watch Professor John Radford's video explaining the importance of research at The Christie
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Content ArticleA just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong. How do you respond to the people involved? What do you do to minimise the negative impact, and maximise learning? This edition of Sidney Dekker’s extremely successful Just Culture offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety reporting and honest disclosure, about retributive just culture and about the decriminalisation of human error.
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Content ArticleINQUEST's evidence-based report Stolen lives and missed opportunities: the deaths of young adults and children in prison, documents the deaths of 65 young people and children in prison between 2011 and 2014. In the four years covered, INQUEST reveals an average of more than one young death each month.
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Content ArticleThis paper, published by Science Daily, highlights how a multidisciplinary group of leaders established consensus-driven research agenda designed to create a path forward to inform approaches that better support harmed patients and families.
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Content ArticleThis presentation, delivered by Margaret Murphy, Lead Advisor for the World Health Organization, took place at the Patient Safety Learning conference. In this short video, Margaret argues that the hear of the matter is in the patient'd and families experiences of care and how this, alongside true engagement, can be used to drive improvement.
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Content ArticleIn this blog, Steven Shorrock discusses Learning Teams, small group conversations and action, and makes a case for learning in the following ways: talk about everyday work start with what’s strong, not what’s wrong find ways to cross departmental boundaries and get multiple perspectives understand first what can be done by teams.
