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Showing results for tags 'Organisational learning'.
Found 540 results
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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 ArticleA framework to support ambulance trusts in England to learn from deaths in their care.
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Content ArticlePresentation slides from Salford University's Patient Safety Conference.
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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.
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Content ArticleThis document from the World Health Organization (WHO) is to urge the readers to understand the purpose, strengths and limitations of patient safety incident reporting. Data derived from incident reports can be very valuable in understanding the scale and nature of harm arising from health care, provided that the properties of the data are reviewed carefully and conclusions are drawn with caution. The use of incident reporting systems for true learning in order to achieve sustainable reductions in risk and improvements in patient safety is still work in progress. It can be and has been done, but not yet on the scale and with the speed that compares with some other high-risk industries. That is what we must all strive for. This technical guidance will help the journey to a position where we can show patients and their families how we used this learning to give them care that is safe and dependable, every time they need it.
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Content ArticleAlthough many initiatives have been implemented and great strides have been achieved in improving patient safety and reducing preventable medical errors, progress towards achieving "zero" avoidable harm continues to be slow. This video presentation will address common medical errors, their recognition, potential for harm and the psychological and financial costs. The concepts of human factors, system design and the high reliability organisation will be reviewed. New approaches in reducing harm and restoring trust will be described along with the opportunity for physician leadership.
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Content ArticleDr Bill Kirkup, Chairman of the Morecambe Bay Investigation, presented at the Patient Safety Learning Conference on the common themes that have emerged, and the lessons we need to learn, from the numerous high-profile inquiries in which he has played a leading role.
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Content ArticleLearning from deaths of people in their care can help providers improve the quality of the care they provide to patients and their families, and identify where they could do more. A CQC review in December 2016, 'Learning, candour and accountability: a review of the way trusts review and investigate the deaths of patients in England' found some providers were not giving learning from deaths sufficient priority and so were missing valuable opportunities to identify and make improvements in quality of care. This video from the NHS Improvement national patient safety team is a guide for NHS trusts in England on developing and implementing learning from deaths policies within their organisations.
