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Showing results for tags 'Organisational learning'.
Found 542 results
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Content ArticleIn our Blueprint for Action, we outline some of the concerns around the quality of investigations.
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Content ArticleThe purpose of the International Classification for Patient Safety (ICPS) is to enable categorisation of patient safety information using standardized sets of concepts with agreed definitions, preferred terms and the relationships between them being based on an explicit domain ontology (e.g., patient safety). The ICPS is designed to be a genuine convergence of international perceptions of the main issues related to patient safety and to facilitate the description, comparison, measurement, monitoring, analysis and interpretation of information to improve patient care. Download visual representation of the framework
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Content ArticleIn our previous blog we shared some reflections about the recent case of Dr Gawa-Barba and the implications the case has for the promotion of a learning culture in healthcare. In light of the Gawa-Barba case, the Government set up a review to which we have submitted a paper.
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Content ArticleDrawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring.
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Content ArticlePresentation from Dr Helen Highham at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
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Content ArticleThrough 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.
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Content ArticleInpatient falls are one of the most common patient safety incidents reported in rehabilitation wards in Australia and can result in serious adverse patient outcomes, including permanent physical disability and occasionally death. Camden Hospital in Australia implemented a multidisciplinary review meeting (Safety Huddle) following all inpatient falls and near miss falls, which developed strategies in consultation with the patient to prevent the incident from reoccurring.
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Community PostFabulous conference. Please share your take away actions and start a discussion
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Content ArticleHealthcare systems are under stress as never before. An ageing population, increasing complexity and comorbidities, continual innovation, the ambition to allow unfettered access to care and the demands on professionals contrast sharply with the limited capacity of healthcare systems and the realities of financial austerity. This tension inevitably brings new and potentially serious hazards for patients and means that the overall quality of care frequently falls short of the standard expected by both patients and professionals. The early ambition of achieving consistently safe and high-quality care for all1 has not been realised and patients continue to be placed at risk. In this paper published in BMJ Quality & Safety, Amalberti and Vincent discuss the strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to.
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Content Article"Among many other opportunities created by the launch of the World Alliance for Patient Safety is the hope that one day the learning from the inadvertent death of a patient in a hospital in one country could save the lives of many others around the world." In his paper, Sir Liam Donaldson (Chair of the WHO World Alliance for Patient Safety at the time) talks about the importance of global collaboration for patient safety.
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Content ArticleThis Care Quality Commission (CQC) briefing document discusses the need for a change in the way that serious incidents are investigated and managed in the NHS. It is based on the findings of a review of a sample of serious incident investigation reports from 24 acute hospital trusts. This sample represented 15% of the total 159 acute hospital trusts in England at the time of review. The briefing provides a summary of the findings, linked to five opportunities for improvement and calls for all organisations to work together across the system to align expectations and create the right environment for open reporting, learning and improvement.
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Content ArticleAs improvement practice and research begin to come of age, Mary Dixon-Woods in this BMJ feature considers the key areas that need attention if we are to reap their benefits. Mary Dixon-Woods is the Health Foundation Professor of Healthcare Improvement Studies and Director of The Healthcare Improvement Studies (THIS) Institute at the University of Cambridge, funded by the Health Foundation. Co-editor-in-chief of BMJ Quality and Safety, she is an honorary fellow of the Royal College of General Practitioners and the Royal College of Physicians.
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Content ArticleA report for Norfolk and Suffolk NHS Foundation Trust by Verita. Verita is an independent consultancy that specialises in conducting and managing investigations, reviews and inquiries for regulated organisations.
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Content ArticleIn 2016, a national review by the Care Quality Commission (CQC) found that the NHS was missing opportunities to learn from patient deaths and that too many families were not being included or listened to when an investigation happened. A key recommendation from this review was that a national framework be developed, so that NHS Trusts have clarity on the actions required when someone dies in their care. The National Guidance on Learning from Deaths published by the National Quality Board (NQB) in March 2017, recommended all Trusts to publish a policy on how the organisation responds to and learns from deaths of patients who die under their management and care. The frameworks purpose is to initiate a standardised approach for reporting, investigating and learning from deaths in care.
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Content ArticleThis policy confirms the process for reviewing deaths within Lincolnshire Community Health Services (LCHS) to ensure a consistent approach is followed in order to identify if the patient’s needs were met during the end of life phase and that relatives and carers were supported appropriately. The aim of the mortality review process is to identify any areas of practice that require improvement and to identify areas of good practice. This process ensures that mortality within LCHS is managed and reviewed in a systematic way.
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Community Post
Definition of "Lessons Learned"
Haydn Williams posted a topic in Methodology and guidance: How to do an investigation
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I've been searching for a definition of "Lessons Learned", to inform some internal discussion and a policy review. However, I cannot seem to find one anywhere - I've tried as much NHSI and old NPSA documentation as I can get my hands on, Googled some Trust policies, and done some other searches. The closest I can find is some wording on Knowledge for Healthcare: This seems to be a start, but not necessarily specific to incidents and learning from investigations. I'm also keen to use wording from an organisation which already carries a bit of weight and gravitas, rather than developing our own, if possible. Is anyone aware of anything I might have missed?- Posted
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Content ArticleSafety in aviation has often been compared with safety in healthcare. This article, published in JRSM Open, presents a comprehensive review of similarities and differences between aviation and healthcare and the application to healthcare of lessons learned in aviation.
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Content Article
Letter from America: A Grand Adventure
lzipperer posted an article in Letter from America
‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery.- Posted
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Content ArticlePublished in Systematic Reviews, this paper looks at how organisations need to systematically identify contributory factors (or causes) which impact on patient safety in order to effectively learn from error. Investigations of error have tended to focus on taking a reactive approach to learning from error, mainly relying on incident-reporting systems. Existing frameworks which aim to identify latent causes of error rely almost exclusively on evidence from non-healthcare settings. In view of this, the Yorkshire Contributory Factors Framework (YCFF) was developed in the hospital setting. Eighty-five percent of healthcare contacts occur in primary care. As a result, this review will build on the work that produced the YCFF, by examining the empirical evidence that relates to the contributory factors of error within a primary care setting.
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Content ArticleEffective communication is critical to successful large-scale change. Yet, in our experience, communications strategies are not formally incorporated into quality improvement frameworks. The 1000 Lives Campaign was a large-scale national quality improvement collaborative that aimed to save an additional 1000 lives and prevent 50 000 episodes of harm in Welsh health care over a two year period. This research, published in the Journal of Communication in Healthcare, used the campaign as a case study to describe the development, application, and impact of a communications strategy embedded in a large-scale quality improvement initiative.
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Content ArticleSpreading successful improvement work across the NHS is an essential part of improving health care quality and efficiency. Yet all too often an idea that has been shown to work well in one place is not adopted by others who could benefit from it. This guide from the Health Foundation, intended for those actively engaged in health care improvement, draws on this experience and empirical evidence, to provide practical information about how communications approaches can be used to spread improvement ideas.
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Content ArticleThe National Patient Safety Agency developed the Incident Decision Tree to help NHS managers in the UK to determine a fair and consistent course of action toward staff involved in patient safety incidents. Research shows that systems failures are the root cause of the majority of safety incidents. Despite this, when an adverse incident occurs, the most common response is to suspend the clinician(s) involved, pending investigation, in the belief that this serves the interests of patient safety. The Incident Decision Tree supports the aim of creating an open culture, where employees feel able to report patient safety incidents without undue fear of the consequences. The tool comprises an algorithm with accompanying guidelines and poses a series of structured questions to help managers decide whether suspension is essential or whether alternatives might be feasible.
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Content Article
EAST: Four simple ways to apply behavioural insights (2015)
Patient Safety Learning posted an article in Techniques
If you want to encourage a behaviour in any setting, make it Easy, Attractive, Social and Timely (EAST). These four simple principles for applying behavioural insights are based on the Behavioural Insights Team’s own work and the wider academic literature. There is a large body of evidence on what influences behaviour, and we do not attempt to reflect all its complexity and nuances here. But we have found that policy makers and practitioners find it useful to have a simple, memorable framework to think about effective behavioural approaches. -
Content ArticleIn this briefing, the Improvement Analytics Unit (a partnership between the Health Foundation and NHS England) identifies some early signals of changes in hospital use by vanguard care home residents in Wakefield, in order to inform local learning and improvement.
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Content ArticleThis case story is based on real events and NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. Although the case occurred in the emergency department there is learning for other departments. As you read about this incident, please ask yourself: Could this happen in my organisation? Who could I share this with? What can we learn from this?
