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Showing results for tags 'Organisational learning'.
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Content ArticleIn this guest blog for the Professional Standards Authority, Peter Walsh, Chief Executive of Action against Medical Accidents (AvMA), sums up what progress has been made since the introduction of the organisational and professional duties of candour, but also questions what difference they have made. Peter remains hopeful, that the duty of candour will become much more than just a box-ticking exercise and believes, if we can get it right, it will be the biggest and most overdue advance in patients’ rights and patient safety that we have ever seen in health and social care.
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Content Article
The human-centred organisation (11 May 2020)
Patient Safety Learning posted an article in Techniques
The world today is highly complex and fast changing. New technologies become available and change the way we work, communicate and live our lives. The complex socio-economic and socio-political systems can make it difficult to anticipate the needs and requirements of tomorrow. This article discusses issues organisations have to deal with and the benefit of becoming more human-centred with help of a model aiming to influence organisations on policy level. -
Content ArticleChallenges to the status quo present leaders with the opportunity and responsibility to not only respond but to learn and transform the system. This article from Slotkin et al. shares the experience of leaders at a large health system to design an emerging COVID response to effectively innovate to sustain improvement.
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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
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Content Article
Choices for the “New Normal” (4 May 2020)
Patient Safety Learning posted an article in Blogs
No one can say with certainty what the consequences of this pandemic will be in 6 months, let alone 6 years or 60. Some “new normal” may emerge, in which novel systems and assumptions will replace many others long taken for granted. But at this early stage, it is more honest to frame the new, post–COVID-19 normal not as predictions, but as a series of choices. In this article in JAMA, Donald Berwick proposes six properties of care for durable change: tempo, standards, working conditions, proximity, preparedness, and equity. -
Content ArticleIn the summer of 2019, following a televised Panorama programme showing abusive care of people with learning disabilities and/or autism in Whorlton Hall (an independent hospital in the north of England), the Care Quality Commission (CQC) requested an independent review of its inspections of Whorlton Hall. Professor Glynis Murphy was appointed to conduct the review.
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Content ArticleWe can use what we’ve learned from the crisis to make a 21st-century service fit for patients and staff alike, says Joel Schamroth in a blog to the Guardian. This pandemic is forcing us to rethink how we deliver healthcare. For too long patients have experienced fragmented services, administrative hurdles and unreliable lines of communication. The “patient experience” often remains an afterthought in the NHS, leading to worse health outcomes, and costing the NHS dearly. The lesson the public is learning is that money can be made available when it’s deemed to be important. In a matter of weeks COVID-19 has shown us that change is possible.
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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 ArticleSince April 2018, the Healthcare Safety Investigation Branch (HSIB) has been responsible for initiating over 1000 independent safety investigations in NHS maternity services in England. This report summarises eight prominent themes that have emerged through analysis of completed maternity investigations, and how HSIB will explore these themes in more detail during the coming year.
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Content ArticleIn this webinar, (filmed on 24 March for the International Society for Quality in Healthcare) Dr Francesco Venneri shares his experience of the response to COVID-19 in Italy from the perspective of his involvement as both a clinical risk manager and as an emergency front line worker. Dr Venneri speaks passionately of how the response was handled, the positive elements, the criticisms, and also how we can learn from COVID-19 by proposing measures that we can apply in the case of future outbreaks.
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Content Article
Developing the next Global Patient Safety Action Plan - Part 1
PatientSafetyLearning Team posted an article in WHO
Helen Hughes, Patient Safety Learning's Chief Executive, shares her insight from a three day World Health Organisation (WHO) meeting and the development of its Global Patient Safety Action Plan for 2020-2030. -
Content Article
The Ombudsman’s Casework Report 2019 (3 March 2020)
Patient Safety Learning posted an article in Complaints
The Parliamentary and Health Service Ombudsman (PHSO) make final decisions on complaints that have not been resolved by the NHS in England, UK government departments and other UK public organisations. The PHSO look into complaints where someone believes there has been injustice or hardship because an organisation has not acted properly or has given a poor service and not put things right. The PHSO looks into complaints fairly, and the service is free for everyone. This first annual Ombudsman’s Casework Report highlights the breadth of cases received across PHSO's jurisdictions. It is only a small cross-section of the cases completed in 2019. The complaints presented here are typical of many of the complaints seen across PHSO's remit. They include complaints about government bodies and the NHS. -
Content ArticleJoanna is a Partner in the law firm Bevan Brittan LLP. In our interview, Joanna talks about her role supporting healthcare staff through the legal and investigatory processes that follow an adverse event, and why we must do all we can to maximise the opportunity to learn when things go wrong in healthcare.
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Content ArticleMore than 30 years have passed since the near-fatal medication error but Michael Villeneuve, CEO Canadian Nursing Association, recalls the moment with absolute clarity.
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Content ArticleThis pay-walled article, published in The Sunday Times, highlights patient safety concerns identified in relation to West Suffolk hospital, with specific reference to two incidences of avoidable patient harm. In the case of Daniel Parsons, a drugs error caused an adverse affect on the functioning of Daniel's heart and led to his death. The coroner for the inquest concluded that Daniel's death could have been avoided if doctors had heeded the early warning signs of anaphylaxis. The second incident highlighted by the authors is that of Paul Farmer, who was left blind and with severe brain damage following avoidable harm. Concerns raised within the article include: Prioritisation of reputation management (an 'outstanding' status) over patient safety Reluctance to investigate Unfair reprisal for staff raising patient safety concerns Lack of response from Health Secretary Matt Hancock. Further reading: Bullying executives left West Suffolk Hospital staff ‘sobbing, shaking, rocking in despair’ (March 2020)
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Content ArticlePatient Safety Learning's Chief Executive Helen Hughes, alongside Professor Alison Leary and Professor Sara Ryan, talk on BBC Radio 4 about coroner reports that are specifically designed to help prevent future deaths and question whether it's working in practice. Health researchers warn that lives are at risk because warnings from Coroners are not being acted upon. Analysis of more than 1000 Prevention of Future Death reports has identified five themes that come up time and time again. Patient Safety Learning has written to the Chief Coroner because of their concerns about this. Sara Ryan is a mother who believes lessons from her son's death have not been learned.
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Content ArticleIncident reporting systems are commonly deployed in healthcare but resulting datasets are largely warehoused. This study, published in the International Journal of Health Care Quality Assurance, explores if intelligence from such datasets could be used to improve quality, efficiency, and safety. Results indicate that healthcare incident reporting data is underused and, with a small amount of analysis, can provide real insight and application to patient safety.
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Content ArticlePatient Engagement for the Life Sciences is a practical handbook for anyone striving to incorporate patient value in the delivery of medicines from research and development into a practical healthcare setting. This book provides a tangible framework of how this can be achieved with and for patients. Any profits generated from book sales will be donated to International Health Partners UK, Europe's largest coordinator of donated medicines, to support patients around the world.
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Content ArticleThis podcast, is the first in a series, produced by Catalysis, about how to change organisational culture. This episode focuses on board engagement and the support a board needs to offer management during cultural transformation.
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News Article
"Patients are not empowered to prevent their own harm", says Sir Liam Donaldson
Patient Safety Learning posted a news article in News
Today, Sir Liam Donaldson is chairing a patient safety meeting at the World Health Organization (WHO) 'A Global Consultation – A decade of Patient Safety 2020–2030' to formulate a Global Patient Safety Action Plan. His introductory address this morning focused on the task ahead – to maintain the World Health Assembly resolution momentum and patient safety as a global movement. "Patients are not empowered to prevent their own harm", Donaldson said, as he highlighted patient stories of unsafe care and the alarming parallels of patient and family experiences across the world. So where is the power? Donaldson went on to to highlight how the six current power blocks are not doing enough to improve safety and that we need to engage and motivate these power blocks to achieve change: Designing of health systems – we have not seen much evidence of systems being designed for safety. Health leaders are not using their power to lead for reduced harm. Educational institutions – these have to happen faster to train staff in. Research community – has patient safety research led to sustainable reduction in risk? Data and information – how has this improved patient safety? Industry – pharma doing very little on medication packaging and labelling; medical devices industry also could do more. -
Content Article
Silent witness – My experience when filing an incident report
Anonymous posted an article in Florence in the Machine
A newly qualified nurse describes what happened when she reported her first Datix for a serious incident.- Posted
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Content ArticleThis blog, written by Human Factors expert Stephen Rice and published by Forbes, looks at what healthcare can learn from the success of the aviation industry when it comes to safety.
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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 ArticleLearn how the key principles of safe design – standardize care, create independent checklists for important processes, and learn from defects – can be applied to create safer systems that benefit patients, health care teams, and hospitals.
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Community Post
Restorative justice: can we use it in healthcare to repair harm?
PatientSafetyLearning Team posted a topic in Culture
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Restorative justice brings those harmed by crime or conflict and those responsible for the harm into communication, enabling everyone affected by a particular incident to play a part in repairing the harm and finding a positive way forward. This is part of a wider field called restorative practice. Restorative practice can be used anywhere to prevent conflict, build relationships and repair harm by enabling people to communicate effectively and positively. This approach is increasingly being used in schools, children’s services, workplaces, hospitals, communities and the criminal justice system. What are your thoughts on how this approach would work in a healthcare setting? Does anyone have any experience of using restorative practice?- Posted
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