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Found 540 results
  1. Content Article
    This report examines the key factors at work in organisational failure and learning, a range of practical experience from other sectors and the present state of learning mechanisms in the NHS before drawing conclusions and making recommendations. It's recommendations include the creation of a new national system for reporting and analysing adverse health care events, to make sure that key lessons are identified and learned, along with other measures to support work at local level to analyse events and learn the lessons when things go wrong.
  2. Content Article
    Patients are increasingly being asked for feedback about their healthcare experiences. However, healthcare staff often find it difficult to act on this feedback in order to make improvements to services. This paper, published by Social Science & Medicine, draws upon notions of legitimacy and readiness to develop a conceptual framework (Patient Feedback Response Framework – PFRF) which outlines why staff may find it problematic to respond to patient feedback.
  3. Content Article
    There is little research focusing on how bereaved families experience NHS inquiries and investigations. Despite this gap, there is a consistent assumption that these processes provide families with catharsis. Drawing on her personal experiences of NHS investigations over a five‐year period after the death of her son, Connor Sparrowhawk, the author suggests the assumption of catharsis is misplaced and works to erase the considerable emotional ‘accountability’ labour that families undertake during these processes. She further question whether inquiries or investigations are an effective way of holding stakeholders to account. She concludes with two points: first, qualitative research is needed to better understand bereaved family experiences of inquiries and investigations and second, the ‘lessons learned’ objective underpinning inquiries should be replaced with ‘leading to demonstrable change’, which is what families typically want.
  4. Content Article
    A problem solving tool that captures everything you need on one piece of paper. Now that sounds pretty useful.  In her latest blog, Sally Howard, Topic Lead for the hub, summarises 'A3', a problem solving tool that does exactly that. She draws on her own experience of using the tool to improve patient outcomes and provides both rich insight and practical examples to help others maximise it's potential.
  5. Content Article
    This paper explores how patient-reported experience measures (PREMs) are collected, communicated and used to inform quality improvement (QI) across healthcare settings.
  6. Content Article
    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.
  7. Content Article
    Sam Morrish, a three-year-old boy, died from sepsis on 23 December 2010. An investigation, undertaken by the Parliamentary and Health Service Ombudsmen (PSHO) in 2014, found that had Sam received appropriate care and treatment, he would have survived. Yet, previous NHS investigations failed to uncover that his death was avoidable. So the family asked PSHO to undertake a second investigation to find out why the NHS was unable to give them the answers they deserved after the tragic death of their son.
  8. Content Article
    Safety in healthcare has traditionally focused on avoiding harm by learning from error. This approach may miss opportunities to learn from excellent practice. Excellence in healthcare is highly prevalent, but there is no formal system to capture it. We tend to regard excellence as something to gratefully accept, rather than something to study and understand. Our preoccupation with avoiding error and harm in healthcare has resulted in the rise of rules and rigidity, which in turn has cultivated a culture of fear and stifled innovation.
  9. Content Article
    Helen Marie Bousquet tragically passed away after what has been described by her son as 'a basic routine procedure' for knee surgery. He argues that her tragic and avoidable death highlights the need for better assessment of patients for sleep apnea and for better treatment and monitoring of these patients before, during and after surgery. The recent jury finding that a hospital nurse was negligent in the care of Helen Marie Bousquet raises the question whether negligence can result in safer patient care. In his blog, Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), looks at this case and the lessons that can be learned.
  10. Content Article
    A study showed that when doctors tell heart patients they will die if they don't change their habits, only one in seven will be able to follow through successfully. Desire and motivation aren't enough: even when it's literally a matter of life or death, the ability to change remains maddeningly elusive. Given that the status quo is so potent, how can we change ourselves and our organisations? In Immunity to Change, authors Robert Kegan and Lisa Lahey show how our individual beliefs, along with the collective mind-sets in our organisations, combine to create a natural but powerful immunity to change. By revealing how this mechanism holds us back, Kegan and Lahey give us the keys to unlock our potential and finally move forward. And by pinpointing and uprooting our own immunities to change, we can bring our organisations forward with us. This persuasive and practical book, filled with hands-on diagnostics and compelling case studies, delivers the tools you need to overcome the forces of inertia and transform your life and your work.
  11. Content Article
    The New Year often encourages us to talk about change and to look ahead at what we want to achieve in the coming months as individuals, teams and organisations. In her latest blog, Sally Howard, topic leader for the hub, draws attention to the Immunity to change theory and outlines four key steps for realising our aspirations and making change happen.
  12. Content Article
    Action against Medical Accidents (AvMA) provides a list of patients/family members with lived experience of patient safety issues who can speak at events, help with training, or provide consultancy.
  13. Content Article
    The objective of this Australian paper, published in the International Journal for Quality in Health Care, was to develop, implement and evaluate a system-wide 'challenge' with the aim of improving safety and quality.
  14. Content Article
    Hospital Watchdog is a nonprofit patient advocacy organisation in the US that champions safe hospital care for patients. They are a diverse group that includes nurses, physicians, pharmacists, healthcare experts, attorneys and members of the public. Some of them have experienced or witnessed medical errors that led to an extremely serious or tragic outcome. They are committed to improving unsafe conditions in hospitals. In February 2019, Hospital Watchdog conducted an in-depth interview with Ms. Dena Royal, a former paramedic, and respiratory therapist. Dena’s mother, Martha Wright, bled to death following a colonoscopy and a series of tragic nursing mistakes at Cass Regional Medical Center in Harrisonville Missouri.
  15. Content Article
    The Culture Code reveals the secrets of some of the best teams in the world – from Pixar to Google to US Navy SEALs – explaining the three skills such groups have mastered in order to generate trust and a willingness to collaborate. Combining cutting-edge science, on-the-ground insight and practical ideas for action, it offers a roadmap for creating an environment where innovation flourishes, problems get solved and expectations are exceeded.
  16. Content Article
    Charles Vincent and René Amalberti set out a system of safety strategies and interventions for managing patient safety on a day-to-day basis and improving safety over the long term. These strategies are applicable at all levels of the healthcare system from the frontline to the regulation and governance of the system. There have been many advances in patient safety, but we now need a new and broader vision that encompasses care throughout the patient’s journey. The authors argue that we need to see safety through the patient’s eyes, to consider how safety is managed in different contexts and to develop a wider strategic and practical vision in which patient safety is recast as the management of risk over time. Most safety improvement strategies aim to improve reliability and move closer toward optimal care. However, healthcare will always be under pressure and we also require ways of managing safety when conditions are difficult. We need to make more use of strategies concerned with detecting, controlling, managing and responding to risk. Strategies for managing safety in highly standardised and controlled environments are necessarily different from those in which clinicians constantly have to adapt and respond to changing circumstances.
  17. Content Article
    Through speaking with Royal College of Paediatrics and Child Health (RCPCH) Members, child health workers and reviewing existing resources, it was identified that there was a lack of practical 'how to' materials to support professionals in delivering face to face sessions with children, young people and families. The impact was two-fold. Some professionals felt they didn’t have the confidence or skills to involve children, young people or families and ensure they had a voice. In addition,  young patients and their families were not consistently involved in providing feedback on services, in identifying gaps, reviewing service deliverables and being involved collaboratively with professionals to develop and test solutions. Ultimately it provides a missed opportunity to provide a service-user centred service that meets their needs as well as the potential for reducing long term disengagement with treatment plans.  This would inevitably impact on patient safety.  By having a service that actively listens and involves the service users strategically, is fit for purpose, meets the needs of the patient, family and professional and has shared ownership in developing the best service possible, services can become more effective and efficient. 
  18. Content Article
    A safety culture is built on trust. It empowers staff to report errors, near misses, and recognise unsafe behaviours and conditions that can put patients at risk, all of which drive improvement.   This video by the Joint Commission Centre for Transforming Healthcare explains how they are engaging staff and the importance of speaking up.
  19. Content Article
    Staff at C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital, Michigan are adopting a new approach to safety. By picking up near misses, close calls, deviation off protocol and investigating each one via a daily huddle, they are able to enable change system wide.
  20. Content Article
    Annie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without the knee-jerk blame and shame approach of old.
  21. Content Article
    What is the Autism Act? The Autism Act 2009 was the result of two years of active campaigning, with thousands of National Autistic Society members and supporters persuading their MPs to back Cheryl Gillan MP’s Private Members Bill. It is the only act dedicated to improving support and services for one disability.
  22. Content Article
    This area of the Royal College of Obstetricians and Gynaecologists website provides guidance for healthcare professionals on obtaining consent from women within obstetrics and gynaecology services. It provides easy access to all procedure-specific consent documentation and gives advice on how best to support women’s decision-making about their care.
  23. Content Article
    In the UK, each year over 1000 babies die or are left with severe brain injury, not because they are born too soon or too small, or have a congenital abnormality, but because something goes wrong during labour. The Royal College of Obstetricians and Gynaecologists does not accept that all of these are unavoidable tragedies, and with the Each baby counts project, they are aiming to reduce this unnecessary suffering and loss of life by 50% by 2020.
  24. Content Article
    This is a story of a patient in whom the emergency department missed the same diagnosis twice, four years apart. The first occasion (prior to his diagnosis of ankylosing spondylitis) was understandable. The second was not. As a result of this case, the hospital have changed their x-ray policy for non-traumatic back pain. They also want to share key learning points (the majority of which were due to lack of awareness about a relatively rare condition and its complications) as widely as possible, to help others avoid the same errors.  This reflective learning features guest educator, Mr Gareth Dwyer (the patient).
  25. Content Article
    Sally Howard, topic leader for the hub, shares her insight on the imminent NHS Improvement Framework after she attended a webinar with National Director of Improvement for NHS England and NHS Improvement, Hugh McCaughey.
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