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Showing results for tags 'Organisational learning'.
Found 540 results
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Content ArticleDr Holly Mincher, Paediatric speciality doctor in training, Somerset NHS Foundation Trust, shares her experience of being involved with Care Opinion. Care Opinion is a website where anyone can share their experience of health or care services, and help make them better for everyone.
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Content ArticleCommunity hospitals are an important part of local health and care systems, yet there has been very little shared on their role and contribution during the pandemic. This project from the Community Hospitals Association sought to redress this and highlight the role of these local hospitals. This two-year project enabled staff to reflect on their experiences and innovations in their community hospitals during the pandemic in a systematic way that facilitated wider sharing and learning. It captures the experiences of staff working in UK community hospitals during the COVID-19 pandemic, with a focus on positive impact changes.
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Content ArticleThis summary of how a National Patient Safety Board (NPSB) will benefit patients and families was coproduced by the NPSB Advocacy Board with Patients for Patient Safety US. It outlines how the NPSB would ensure more comprehensive learning from patient safety incidents, ensure patients and families have a core role in governance and priority setting and that data is used to better understand patient safety in the US.
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Content ArticleAgainst the backdrop of the Covid-19 pandemic, ensuring the safety of health and social care services remains a serious, ongoing challenge. This report examines how patient safety governance mechanisms in Organisation for Economic Co-Operation and Development (OECD) countries have withstood the test of Covid-19. It provides recommendations for further improving patient safety governance and strengthening health system resilience in OECD countries. This working paper was produced by the OECD for the 5th Global Ministerial Summit on Patient Safety, held in Montreux, Switzerland in February 2023.
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Content ArticleThe Scottish Patient Safety Programme (SPSP) is a national quality improvement programme that aims to improve the safety and reliability of care and reduce harm. Since the launch of SPSP in 2008, the programme has expanded to support improvements in safety across a wide range of care settings including Acute and Primary Care, Mental Health, Maternity, Neonatal, Paediatric services and medicines safety. Underpinned by the robust application of quality improvement methodology SPSP has brought about significant change in outcomes for people across Scotland.
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Content ArticleIn this podcast to support providers with the transition to the Learn from Patient Safety Events (LFPSE) service, the NHS's new national system for the recording and analysis of patient safety events, NHS England talks to Zahra and Mandy, NHS England reporting leads, about the practical steps providers can take to get connected to LFPSE. It covers how to get started, what to do with your old data, the kinds of support available, what transition means for ICBs, and what the Reporting Leads have learned from the process so far.
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Content ArticleIn this blog, Judy Walker, an After Action Review (AAR) expert, looks at how effective learning from disasters and incidents can restore hope and trust, offering long-term improvements to systems that have failed. She talks about how public inquiries, although they can seem frustratingly slow, benefit society when the relevant authorities ensure that learning is understood and implemented. She compares this to the impact of AARs, highlighting that people’s trust in the process is linked to their perception of the changes that happen as a result of the AAR. She outlines three steps that NHS providers should take to ensure the AAR process is effective in restoring hope: Highlight to all staff on a regular basis, the benefits that are being delivered due to AARs Ensure patients and family members are provided with specific information about how AARs prevent future harms Support the people who lead AARs to do so skilfully, so that quality is assured and staff can trust in the safety and value of the process.
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International Forum on Quality and Safety in Healthcare
Sam posted an event in Community Calendar
untilThe Institute for Healthcare Improvement (IHI) and BMJ bring you one of the largest international conferences focused on improving outcomes for patients and communities through quality improvement. Themed Adapting to a changing world: equity, sustainability and wellbeing for all, the conference programme will focus on how the improvement movement can help healthcare systems adapt and thrive in a rapidly changing world. Key topics we will address include equity, sustainability, wellbeing and learning from adverse events. Further information and registration -
Content ArticleThis report considers the number of safety incidents in surgery occurring in the NHS since 2015 and calls for action to improve surgical safety. It also highlights the perceptions of patients from a survey of people who have had surgery in the last five years. It is authored by surgical care platform Proximie, with support from experts in the surgical space.
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Content Article
Safety culture: learning from best practice (15 November 2022)
Patient-Safety-Learning posted an article in Culture
This document outlines NHS England's approach to learning from safety culture best practice. It covers: Safety culture context within the NHS patient safety strategy Leadership Continuous learning and improvement Measurement and systems Teamwork and communication Psychological safety Inclusion, diversity and narrowing healthcare inequalities Case studies -
Content ArticleIn this blog, Matthew Wain highlights how NHS organisations can support staff with patient safety investigations, and more generally, in the face of increased pressure. He looks at missed learning opportunities, psychological impact, and the support tools and programmes available for staff. Further reading: Patient Safety Learning's Staff Support Guide: a good practice resource following serious patient harm
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Learning from Never Events
Patient Safety Learning posted an event in Community Calendar
Never events are defined as “serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” They are designed to act as a red flag for improvement by NHS organisations. This one day masterclass will focus on safety culture around Never Events within healthcare organisations. There were 364 never events in 2020/21 and 349 between April 2021 and Jan 2022. The masterclass will look at how Never Events have been investigated and at Human Factors approaches to improving learning and the systems to reduce harm. It will compare our experiences with learning from serious incidents from other countries. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/learning-from-never-events or email kate@hc-uk.org.uk. hub members receive a 20% discount, Email info@pslhub.org for discount code. -
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Investigation and learning from deaths
Patient Safety Learning posted an event in Community Calendar
This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. The conference will also include a split stream where delegates can chose to focus on investigating and learning from either deaths in acute care, or deaths in primary and community care. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/investigation-learning-deaths-hospital-mortality or email aman@hc-uk.org.uk. With only a few places left, HCUK are offering hub members five discounted places at only £195+VAT with discount code HCUK195PSL. Follow the conference on Twitter @HCUK_Clare #LFDNHS -
Content ArticleIn this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
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Content ArticleIn this article, Roger Kline, Research Fellow at Middlesex University, explains what caused the sinking of the Herald of Free Enterprise ferry. The sinking of the Herald of Free Enterprise on March 6 1987 with the loss of 198 lives was an accident waiting to happen, highlighting the devastating consequences of abandoning safe working practices in the name of financial savings. Human factors science learned from the Herald disaster is widely applied in sectors as diverse as nuclear power stations and healthcare.
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Content ArticleNHS England has recorded two podcasts sharing insight and advice from organisations that have completed the transition from the National Reporting and Learning System (NRLS) to the new Learn from Patient Safety Events (LFPSE).
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Content ArticleIncident reporting is a crucial tool for improving patient safety, alongside an open culture that supports this. In the NHS the new Learn from Patient Safety Events (LFPSE) service is now being rolled out to replace the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS). This article details correspondence between Patient Safety Learning and NHS England in relation to concerns raised by staff about the development and implementation of the LFPSE service
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EventThe publication of the New Patient Safety Incident Response Framework in August 2022 has shifted the focus towards identifying and investigating patient safety incidents and events that have the greatest potential to lead to learning and improvement. This conference focuses on patient safety learning – maximising learning and improvement from patient safety insight and events. The conference will support you to identify incidents and insight that has the greatest potential for improvement and use a range of system-based approaches for learning from patient safety incidents. The conference will also update delegates on the new Learn from patient safety events (LFPSE) service and how local incident reporting will adapt to this new system. The roles and competencies of the Learning Response Lead, and the practicalities of involving and engaging with patients to deliver continuous improvement will also be discussed. Finally the conference will share examples of Safety Actions & After Action Reviews which is recommended under the new framework. This conference will enable you to: Network with colleagues who are working to improve the learning from Patient Safety Insight and Events. Update your knowledge on the New Patient Safety Incident Response Framework published in August 2022. Ensure your approach to learning is in line with PSIRF. Understand the new roles of Patient Safety Partner, Patient Safety Specialist and Learning Response Lead. Identifying and prioritise incidents that have the greatest potential for learning. Explore the requirements and value of the Learn from patient safety events (LFPSE) service. Reflect on the perspectives of a patient who has been engaged as a patient safety partner, and understand how to engaging and involving patients, families and staff can lead to improvement. Understand behaviours, decisions and actions that allow continuous learning and improvement. Develop practical approaches to better aligning the work of patient safety and quality improvement teams. Understand how to work with staff to ensure a focus on learning and continuous improvement. Develop your skills in Leading Patient Safety Improvement and techniques for ensuring a system-based approach to learning. Identify key strategies for delivering Safety Actions & After Action Reviews: Delivering, accountability and monitoring. Supports CPD professional development and acts as revalidation evidence. This course provides 5 hours training for CPD subject to peer group approval for revalidation purposes. Register We have five free places for hub members. To secure the places, simply quote HCUK00PSL.
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Learning from Excellence - Adrian Plunkett
Patient Safety Learning posted an event in Community Calendar
untilEmail rduh.qit@nhs,net to book a place. -
Content ArticleOn 9 November 2022, The Professional Standards Authority hosted the Safer care for all conference to discuss questions and issues highlighted in the report Safer care for all – solutions from professional regulation and beyond. This webpage contains video summaries of the conference sessions. The conference provided an opportunity to hear experts’ views as well as consider and contest the themes raised in the report, including the PSA's main recommendation, the creation of a health and social care safety commissioner in all four UK countries. Speakers and delegates came from both professional and system regulators as well as patient organisations, the ombudsman, the NHS, health and care sector organisations and major healthcare inquiries.
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Content ArticleIn this podcast, the Learn from Patient Safety Events (LFPSE) team talks to the National Director for Patient Safety about the new LFPSE service, why it’s important, and the benefits he thinks it will bring for patient safety.
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The future of healthcare investigations
Patient Safety Learning posted an event in Community Calendar
untilThis free webinar will explore what the future looks like for this critical area of human factors investigation. The presenters will each talk about a different aspect and there will be time for you to ask questions. The future of healthcare investigation: focus on learning and improvement Mark Sujan will talk about the new NHS England Patient Safety Incident Response Framework (PSIRF) which puts emphasis on learning and improvement. You’ll hear about the limitations of existing approaches to learning from incidents in healthcare, which PSIRF tries to overcome. You’ll then find out about the principles of organisational learning for achieving sustainable change, based on the CIEHF guidance. Transition: HSIB to HSSIB and MNSI HSIB’s Deinniol Owens will reveal that in April 2023, the Healthcare Safety Investigation Branch (HSIB) will transition into two new organisations: The Health Services Safety Investigation Body (HSSIB) and the Maternity and Newborn Safety Investigations (MNSI) Special Health Authority. You’ll get insight into the roles of the new organisations and hear about the additional focus on the new powers and opportunities available to HSSIB now that it’s been confirmed in statute by the Health and Care Act 2022. Investigation education: The transfer of knowledge Andrew Murphy-Pittock will explore one of the key objectives of HSIB, which is to transfer knowledge to those undertaking and overseeing patient safety investigations. You’ll find out how HSIB has developed a flexible, agile programme, working with colleagues at PSIRF, to help healthcare organisations on the move away from the Serious Incident Framework to a systems-focused approach to learning, involving those affected by incidents in the process. You’ll also hear about current and future plans for the education programme. Who will this be of interest to? This webinar should be of interest to healthcare professionals, investigators, change managers, process designers and anyone with an interest in patient safety. Register -
Content ArticleThe Patient Safety Database (PSD), previously called the Anesthesia Safety Network, is committed in the delivery of better perioperative care. Its primary goal is to make visible the lack of reliability of healthcare and the absolute necessity to build a new system for improving patient safety. This year, PSD has also been involved in the development of the SafeTeam Academy, an e-learning training platform associated with the Patient Safety Database, which offers video immersive courses using the power of cinema to train healthcare professionals. This is the latest newsletter from PSD, featuring a wide range of content by safety experts across Europe.
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Content ArticleIn this blog, Judy Walker, Senior Business Consultant at iTS Leadership, describes an After Action Review (AAR) that took place at a large London hospital following the first wave of Covid-19. As part of the AAR, Emergency Department porter Aaron described his experience of the first Covid 19 surge—wheeling large numbers of patients who had died through an empty hospital. Judy describes the value of staff listening to different perspectives as a way to reflect on their own experiences and understand the impact events have on different individuals. She highlights the importance of listening to the process of learning for individuals and teams.
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Content ArticleThe Patient safety incident response framework (PSIRF) represents a new approach to responding to incidents. Under PSIRF, those leading the patient safety agenda within provider organisations, together with internal and external stakeholders (including patient safety partners, commissioners, NHS England, regulators, Local Healthwatch, coroners etc), decide how to respond to patient safety incidents based on the need to generate insight to inform safety improvement where it matters most. Key issues must first be identified and described as part of planning activities before an organisation agrees how it intends to respond to maximise learning and improvement. This guidance has been developed collaboratively between Stop the Pressure Programme, National Wound Care Strategy leads and members of the Patient Safety Team, with the support from the Patient Safety Incident Response Framework (PSIRF) Implementation and Working Groups.
