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Showing results for tags 'Organisational learning'.
Found 540 results
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Content ArticleSue Hignett and Paul Bowie propose taking a much-needed professional approach to patient safety through an accredited learning pathway to integrate safety into clinical systems and develop healthcare safety specialists and experts
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Content ArticleSafety governance refers to the approaches taken to minimise the risk for patient harm across an entity or system. It typically comprises steering and rule-making functions such as policies, regulations and standards. To date, governance has focused on the clinical level and the hospital setting, with limited oversight and control over safety in other parts of the health system. All 25 countries that responded to a 2019 OECD Survey of Patient Safety Governance have enacted legislation that aims to promote patient safety. These practices include external accreditation and inspections of safety processes and outcomes. Safety governance models are also moving away from punishment and shaming towards increased trust and openness. Learning from success as well as failures represents a paradigm shift in safety governance, an approach that has been increasingly adopted in OECD countries.
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Content ArticleJoe Rafferty, Chief Executive of Mersey Care NHS Foundation Trust, explains Mersey Care's strategy to pursue 'perfect care' and why it requires a cultural shift that is dependent on a paradigm shift in mind-set, behaviour and practice.
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS's approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety It is intended to support one of the key aims of the NHS Patient Safety Strategy, to help the NHS improve its understanding of safety by drawing insight from patient safety incidents. This will replace the Serious Incident Framework with organisations expected to transition to PSIRF within 12 months of its publication, by Autumn 2023.
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Content ArticleImproving patient safety culture (PSC) is a significant priority for OECD countries as they work to improve healthcare quality and safety—a goal that has increased in importance as countries have faced new safety concerns connected to the COVID-19 pandemic. Findings from this OECD benchmarking work in PSC show that there is significant room for improvement.
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Content Article
A series of failures: a relative's story
Patient Safety Learning posted an article in Keeping patients safe
At the first Patient Safety Management Network (PSMN)* meeting of 2022, we were privileged to hear from a bereaved relative about her shocking experience, which reminded us all of why we do what we do. Claire Cox, one of the PSMN founders, invited Susan (not her real name to protect her confidentiality) to share with us the causes of her relative’s untimely death and the poor and shameful experience when she and her GP started to ask questions. This kicked off a valuable and insightful discussion about how patients are responded to when things go wrong and about honesty and blame, patient and family engagement in decision making when patients are terminally ill, and how we need to ensure that the new Patient Safety Incident Response Framework (PSIRF) guidance embeds good practice informed by the real-life experience of patients and staff.- Posted
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Content ArticlePoster from the Princess Alexandra Hospital on their Learning from deaths project.
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Content ArticleThe CQC inspection framework now includes multidisciplinary teams (MDTs) for end of life care, tumours and weekly MDTs for people with complex needs. However lack of time and staff availability for this is a real problem. MDTs are under increasing pressure and are already seeing an erosion of their power to assure safe and appropriate care. Anecdotally, non-attendance by key MDT members is a significant quality issue for many hospitals. This is not a problem of engagement — all MDT members and are willing to provide input — but staffing pressures and the complexity of rostering makes holding these MDT meetings near-impossible. So how do we stop this degradation? How can hospitals better manage the burgeoning requirement for MDTs? One possible answer is to change the emphasis from a single meeting to a managed series of recorded opinions and decisions. If properly supported by the right workflow technology, we can move away from the ‘single-point’ MDT meeting (MDTM) to a ‘multi-point’ MDT process (MDTP) which could allow better and more auditable decisions to be made. Where significant differences of opinion exist, then a meeting can be called – but the MDT members could act independently and in parallel using a suitable recording and monitoring system. In this article, Dr D J Hamblin-Brown explains how this might work.
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In this blog, Patient Safety Learning’s hub Editor, Samantha Warne, summarises a recent Patient Safety Management Network (PSMN) session she joined to hear from James Munro, Chief Executive of Care Opinion, about how patients are using Care Opinion to share their experiences and how Trusts are using the feedback. -
Content ArticleOn 22 September 2021 the Health and Social Care Select Committee launched a new inquiry examining the case for reform of NHS litigation, identifying concerns regarding a significant increase in clinical negligence costs and missed opportunities for learning to improve patient safety. Here is the Association of Personal Injuries Lawyers' response to the call for evidence for the Health and Social Care Select Committee Inquiry. Related reading Patient Safety Learning's response to the NHS Litigation Reform AvMA's response to the NHS Litigation Reform
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Content ArticleHealthcare leaders are bringing renewed attention to patient safety issues that have been overshadowed by another year of the COVID-19 pandemic. Becker's Hospital Review asked patient safety experts the following question: "If you could fix one patient safety issue overnight, what would it be and why?" Read the answers Cynthia Barnard, Vice President of Quality at Northwestern Memorial Healthcare (Chicago), Patricia McGaffigan, Vice President of Safety Programs at the Institute for Healthcare Improvement, Ana Pujols McKee Vice president and CMO and Chief Diversity, Equity and Inclusion Officer at The Joint Commission and Gary Stuck, CMO at Advocate Aurora Health gave.
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Content ArticleHuman factors and ergonomics (HF/E) is concerned with the design of work and work systems. There is an increasing appreciation of the value that HF/E can bring to enhancing the quality and safety of care, but the professionalisation of HF/E in healthcare is still in its infancy. In this paper, Sujan et al. set out a vision for HF/E in healthcare based on the work of the Chartered Institute of Ergonomics and Human Factors (CIEHF), which is the professional body for HF/E in the UK. The authors consider the contribution of HF/E in design, in digital transformation, in organisational learning and during COVID-19.
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Content ArticleIn this clinical case report for the Association of Anaesthetists, the authors reflect on the importance of error reporting and implementing learning from clinical mistakes. They look at several error-related incidents and examine key learning points. They highlight that cases that do not result in serious harm to the patient are not prioritised for entry into databases or national audits, meaning they are less likely to be the subject of system-based improvement projects when compared with more ‘serious’ events. They identify that this may cause gaps in clinicians' awareness of potential risks and error traps. The authors also examine the impact that learning projects based on incident reporting can have on clinicians involved in the initial incidents, highlighting that revisiting errors may prevent individuals from moving on from them.
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Recently an enduring discussion evolved on Twitter on why safety culture is important for patient safety. My reaction, of course, was: it isn’t. Let me explain why. I think it is possible to address safety without addressing safety culture. Or, rather, to focus on actions that will improve both safety performance and safety culture (as a by-product) at the same time. In this blog I propose some of these actions – showing how to create an understanding of how work is (actually) done (rather than what it says on paper), seeing what makes it difficult and identifying what resources are missing. If we address these challenges, then surely we will be able to improve safety and safety culture will follow naturally. -
Content Article
In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, reflects on participating in a recent Health Service Journal (HSJ) Patient Safety Congress webinar, held in association with BD, which considered some of the key emerging patient safety issues for 2022.- Posted
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Content ArticleIn this blog, Gwen Nightingale and Katherine Merrifield from The Health Foundation highlight measures to tackle health inequalities that they would like to see included in the government's White Paper on health disparities, due to be published in Spring 2022. They argue that significant investment and ambitious policy are needed to tackle differences in health outcomes. They highlight five areas of focus: Tackle the wider determinants of health head on A new, whole-government approach to improving health Policy ideas backed with immediate investment Meaningfully measuring success Learning from the past
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Content ArticleDr Nick Woodier, HSIB National Investigator, reflects on the challenges associated with joint surgical care of patients and shares learning that can aid the NHS and the private sector as new national agreements come into force.
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Content ArticleRecording of Ted Baker's presentation at The Royal Society of Medicine's Improving Patient Safety & Care Conference.
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Statement from Sajid Javid, Secretary of State for Health and Social Care, to the House on establishing a Special Health Authority for Independent Maternity Investigations. -
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Stay And Thrive sharing and learning event
Sam posted an event in Community Calendar
untilJoin @StayAndThrive on the 29 of June for a virtual sharing and learning event. This event will focus on building, belonging and maximising personal and professional growth, which are the three fundamental pillars of Stay and Thrive. During the event, you will hear and learn from organisations who are implementing positive practices in relation to two aspects of the bundle. Sign up -
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HSIB Safety Investigations Conference 2023
Patient Safety Learning posted an event in Community Calendar
The annual Healthcare Safety Investigation Branch (HSIB) conference agenda will cover: A focus on patient and family engagement. Sharing learning from HSIB national investigations – what has been learnt and how it can help support and improve local investigation practice. HSIB's maternity investigation programme work with families and trusts. This includes how HSIB implements learning from investigations and where the opportunities are to influence change. HSIB's work on Safety Management Systems. How HSIB's education programme is sharing learning to develop and improve local safety investigations. • An overview of HSIB's international work. Breakout sessions to share knowledge. You will also hear how the HSIB will form into the Health Services Safety Investigations Body and the Maternity and Newborn Safety Investigations (MNSI) function and how this may impact you. Register -
EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). The new Patient Safety Strategy advises that organisations must adopt a new and broader approach to stimulate learning from patient safety incidents. This course is designed to assist healthcare professionals involved in this important work. The main purpose is to provide learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs). Traditionally, root cause analysis has been used as a blanket approach to diagnosing why patient safety have been compromised, but healthcare teams are henceforth being encouraged to adopt a wider range of methods that will both save time and facilitate enhanced learning. The focus is now on appropriate proportionality in response to incidents that occur in their organisation. Register 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. From April 2023, all deaths in the community or acute settings that do not require to be referred to the coroner (non-coronial deaths) will be scrutinised by a medical examiner. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-learning-deaths-hospital-mortality or email frida@hc-uk.org.uk. hub members receive a 20% discount code. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LFDNHS -
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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 -
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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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