Search the hub
Showing results for tags 'Organisational learning'.
Found 542 results
-
Content ArticleThis action plan from the Ipswich & East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group follows on from an infection control norovirus outbreak.
-
Content ArticleThis research project from Oikonomou et al. sought to map out the regulatory landscape for patient safety in the English NHS. Results were published in BMJ Open.
-
Content Article
SHIFT to Safety - Canadian Patient Safety Institute
Claire Cox posted an article in Healthcare Excellence Canada
Established by Health Canada in 2003, the Canadian Patient Safety Institute (CPSI) works with governments, health organisations, leaders and healthcare providers to inspire extraordinary improvement in patient safety and quality. SHIFT to Safety is a major shift to empower staff with the tools and information they need to keep patients safe, at any level. -
Content ArticleIn this podcast by the University of Oxford, Ms Sarah Kessler (producer of the feature-length documentary ‘The Checklist Effect’ and past Lead for Lifebox) discusses and shows clips from ‘The Checklist Effect’, the award-winning documentary inspired by the WHO Surgical Safety Checklist. Professor Shafi Ahmed (Consultant Laparoscopic Colorectal Surgeon at the Royal London Hospital and Associate Dean at Barts and the London Medical School) talks about his passion around innovation, technology, global health and education, and how they marry together.
-
Content Article
NHS Resolution: Annual report and accounts 2020/21
Patient Safety Learning posted an article in NHS Resolution
This performance summary provides an overview of the work of NHS Resolution, including their purpose, key risks to achieving their objectives and a summary of activities they have undertaken over the past year. It sets out the activity to meet the four strategic aims outlined in their business plan for 2020/21. -
Content ArticleA framework to support ambulance trusts in England to learn from deaths in their care.
-
Content ArticlePresentation slides from Salford University's Patient Safety Conference.
-
Content ArticleThis is the sixth annual report produced for the Maternal, Newborn and Infant Clinical Outcome Review Programme, run by the MBRRACE-UK collaboration. The authors analysed 2.3 million pregnancies from 2015-2017 in the UK and Ireland. During that three-year period, 209 women in the UK and Ireland died during their pregnancies or up to six weeks afterwards from pregnancy-related causes. This is equivalent to just over 9 women per 100,000. The leading cause of maternal deaths in the UK is still cardiovascular disease, including heart attacks, heart failure and heart rhythm problems, and there has been no reduction in maternal deaths from heart-related causes for more than 15 years. The full report can be found through the link below, or you can read the lay summary here.
-
Content ArticleA ‘critical incident' is one that challenges your own assumptions or makes you think differently’. They provide the following helpful prompts to guide reflection on critical incidents. Here is a simple example of critical incident reflection produced by Birmingham City University.
-
Content ArticleSerious Incidents in health care are adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. This Framework, set out by NHS England, describes the circumstances in which such a response may be required and the process and procedures for achieving it, to ensure that Serious Incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again.
-
Content ArticleA framework for NHS Trusts and NHS Foundation Trusts on identifying, reporting, investigating and learning from deaths in care set out by the National Quality Board in 2017.
-
Content ArticleNHS England helps illustrate the benefits of business continuity planning and how the planning is implemented during a response. Case studies have been put together from various incident debrief reports from organisations to provide examples of approaches to incident reports and also allow identification of learning across organisations
-
Content ArticleThis pack is for acute, specialist, mental health and community trust boards and specifically trust non-executive directors (NEDs) and non-clinical executive directors. It explains what boards are expected to do in relation to the Learning from Deaths framework.
-
Content ArticleBoth national and maternity investigations are showing a high level of family engagement through an inclusive and innovative model that ensures families have a voice throughout investigations. Here the Healthcare Safety Investigation Branch (HSIB) demonstrate how they involve families in their investigations.
-
Content ArticleThe Faculty of Medical Leadership and Management (FMLM) standards for healthcare teams provides evidence-based guidance on what FMLM expects of healthcare teams focused around four key domains: culture vision and strategy management and people relationships.
-
Content ArticleA presentation by Shelia Yates on root cause analysis and Just Culture. Shelia is trained and educated in the performance of behaviour health services through interpersonal communications and analysis.
-
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.
-
Content Article
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 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.
-
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.
-
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 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.
-
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.
-
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 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.
