Search the hub
Showing results for tags 'Organisational learning'.
-
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.
- Posted
-
- Crisis response
- Investigation
- (and 4 more)
-
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.
- Posted
-
1
-
- Safety culture
- Organisational culture
- (and 10 more)
-
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
- 3 comments
-
1
-
- Patient safety incident
- Patient death
- (and 10 more)
-
Content ArticlePoster from the Princess Alexandra Hospital on their Learning from deaths project.
- Posted
-
- Organisational learning
- Patient death
-
(and 1 more)
Tagged with:
-
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.
- Posted
-
- Leadership
- Collaboration
- (and 6 more)
-
Content ArticleIn 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.
- Posted
-
- Patient engagement
- Patient safety incident
- (and 3 more)
-
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
- Posted
-
- Negligence claim
- Legal issue
- (and 3 more)
-
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.
- Posted
-
- Leadership
- Patient engagement
- (and 4 more)
-
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.
- Posted
-
- Human factors
- Ergonomics
- (and 6 more)
-
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.
- Posted
-
- Anaesthesia
- Surgery - General
- (and 4 more)
-
Content ArticleRecently 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.
- Posted
-
- Safety culture
- Transparency
- (and 7 more)
-
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
- Posted
-
- Health inequalities
- Health Disparities
- (and 2 more)
-
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.
- Posted
-
- Investigation
- Private sector
- (and 5 more)
-
Content ArticleRecording of Ted Baker's presentation at The Royal Society of Medicine's Improving Patient Safety & Care Conference.
- Posted
-
- Quality improvement
- Organisational learning
- (and 1 more)
-
Event
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- Posted
-
- Organisational learning
- Communication
-
(and 1 more)
Tagged with:
-
Event
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- Posted
-
- Investigation
- Patient engagement
- (and 5 more)
-
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.
- Posted
-
- Human factors
- Patient safety incident
-
(and 2 more)
Tagged with:
-
Event
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- Posted
-
- Investigation
- Organisational learning
-
(and 2 more)
Tagged with:
-
Event
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- Posted
-
- Health inequalities
- Quality improvement
- (and 2 more)
-
Event
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.- Posted
-
- Never event
- Organisational learning
- (and 3 more)
-
Event
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- Posted
-
- Investigation
- Patient death
- (and 2 more)
-
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.
-
Event
Learning from Excellence - Adrian Plunkett
Patient Safety Learning posted an event in Community Calendar
untilEmail rduh.qit@nhs,net to book a place.