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Showing results for tags 'Organisational learning'.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Jordan talks to us about his journey from drama school to patient safety, how the new Patient Safety Incident Response Framework (PSIRF) will change the way the NHS looks at safety, and how his love of driving makes him think differently about his role. A transcript of the interview is also available below.- Posted
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Content ArticlePatient safety culture is the foundation of patient safety and refers to a healthcare organisation’s shared values, norms and beliefs that influence staff’s behaviour and actions. This study in BMJ Open Quality aimed to assess nurses’ reporting on the predictors and outcomes of patient safety culture and the differences between patient safety grades and the number of events reported. It aimed to fill a gap in research by looking at patient safety culture in terms of both predictors and outcomes. The author developed a cross-sectional comparative research design and recruited 300 registered nurses to take part in a survey on patient safety culture. The author found that nurses generally perceived patient safety culture as 'moderate', and identified areas that should be prioritised to improve patient safety culture. They concluded that assessing patient safety culture is the first step in improving hospitals’ overall performance and quality of services, and that improving patient safety practices is essential to improving culture and clinical outcomes.
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Content ArticleAs organisations continue to adapt to a faster pace of change and seek to achieve their organisational purpose, it’s essential that the resources and time needed to change are minimised. Improving performance by learning effectively from mistakes is a vital part of the change process but the method of learning employed is critical. In this LinkedIn post, Judy Walker discusses the application of After Action Reviews (AARs).
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Content ArticleOver the few years, the Royal Air Force (RAF) has been going through a cultural evolution. In this episode of the Human Factors podcast, Ian James and Avril Webb give an insight into how the implementation of Human Factors and attitudes to safety have evolved in the RAF, and the positive impact this has had on the organisation.
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Content ArticleThe Ockenden review into the failings in maternity care at Shrewsbury and Telford Hospital NHS Trust in the UK makes for sobering reading. The review focuses predominantly on the period from 2000 to 2019 and estimates that there were significant or major concerns in the care of nine women and more than 200 babies who died while receiving care at the Trust. Many more women and babies suffered serious injuries. It was clear that the Shrewsbury and Telford Hospital NHS Trust did not investigate, learn, change, or listen to families when adverse events occurred. The conclusions of the Ockenden review make it clear that safe staffing levels, a well trained workforce, an ability to learn from incidents, and a willingness and ability to listen to families are all crucial for safe maternity care.
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Content ArticleIn this McKinsey & Co blog, the authors examine how organisations can achieve cohesion among decentralised business units and transform their culture. Drawing on McKinsey's experience supporting organisations through change, they look at how setting a common cultural goal and minimum standards for how each business unit will achieve this goal, can result in lasting performance improvements. They examine the following facets of cultural change: How you’re changing: Organizational oversight What you’re changing: Mindsets and behaviours Who is responsible at the business unit level?
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Content ArticleOn his last day in office as Chief Investigator at the Healthcare Safety Investigation Branch (HSIB), Keith Conradi sent this letter to the Secretary of State for Health and Social Care, outlining his concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB. In his letter, Keith highlights a lack of interest in HSIB investigations and activity from leaders in both NHS England and DHSC, and describes how this attitude permeates both organisations. He also draws attention to a lack of priority and support for patient safety at a structural level, and calls on government and healthcare leaders to take a new approach and introduce a regulated safety management system with appropriate accountability. Patient Safety Learning has written a blog reflecting on Keith Conradi's letter, highlighting the ways in which his concerns align with those consistently raised by Patient Safety Learning.
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Content ArticleThe LeDeR programme, funded by NHS England and NHS Improvement, was established in 2017 to improve healthcare for people with a learning disability and autistic people. LeDeR aims to: Improve care for people with a learning disability and autistic people. Reduce health inequalities for people with a learning disability and autistic people. Prevent people with a learning disability and autistic people from early deaths. LeDeR summarises the lives and deaths of people with a learning disability and autistic people who died in England in annual reports. The 2021 reports were made by researchers at King’s College London collaborating with academic partners at the University of Central Lancashire and Kingston-St George’s University, London, copies of which can be accessed from the link below along with a video summary of the findings and “TakeHome” posters.
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Content ArticleIn two videos, Mark Fewster, Head of Product and Innovation at Radar Healthcare, talks to Marcos Manhaes, NHS Improvement, and Paul Ewers, Milton Keynes University Hospitals NHS Trust, about the journey from the National Reporting and Learning System (NRLS) to Learn from Patient Safety Events (LFPSE) and the future benefits the NHS could see.
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Content ArticleOur health services face an unprecedented challenge in recovering from the pandemic and coping with ongoing waves of covid. With such demand for healthcare services from the general population and covid cases rising once more, some customers are bound to be angry or unhappy. But, as we recover from the pandemic, our handling of complaints must surely change, writes David Oliver in this BMJ article.
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Content ArticleThe Invited Reviews service was formed in 1998 and offers consultancy services to healthcare organisations on which they may require independent and external advice. Reviews provide an opportunity to healthcare organisations to deal with issues and concerns at an early stage. Medical directors (MDs) or chief executive officers (CEOs) of healthcare organisations can request an invited review when they feel the practice of clinical medicine is compromised and there are potential concerns over patient safety. The Royal College of Physicians (RCP) Invited Reviews service has gained a wealth of experience dealing with demanding situations involving individuals, teams, departments and services. This is their learning from invited reviews report. It brings together their experiences across multiple specialities, identifying common themes and crystallising some of our generic findings, which will prove useful to all in clinical leadership roles.
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Content ArticleThe Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for regulating and inspecting the quality and availability of Health and Social Care services in Northern Ireland. The (RQIA) was commissioned to examine the application and effectiveness of the Procedure for the Reporting and Follow-up of Serious Adverse Incidents in Northern Ireland. The review was conducted by an Expert Review Team established by the RQIA and made five recommendations for implementation.
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News Article
‘Innovation put over safety’ at world-famous hospital
Patient Safety Learning posted a news article in News
A world-famous hospital has a culture where some staff may put research interests above patient safety, according to an external investigation. A report published yesterday cited some employees at Great Ormond Street Hospital for Children Foundation Trust as saying “they feel that the hospital sometimes put too much emphasis on pushing the boundaries of science” and “are concerned [this] may lead to a culture where some prioritise innovation over safety in their practice”. The trust’s medical director Sanjiv Sharma commissioned the report into the effectiveness of its safety procedures, from consultancy Verita, in 2020, after families of several patients who died at the hospital raised concerns in the media about how it responded to safety incidents. The report said: “We believe that it is sometimes culturally difficult within Great Ormond Street to accept that things can go wrong and to respond appropriately. We were told that some see the organisation as ‘bullet-proof’ in the face of criticism." “There is also a view outside the trust that some clinicians at Great Ormond Street can find it difficult to accept that something had gone wrong. Some believe that this reflex is deeply ingrained. This is potentially indicative of a culture of defensiveness. Acknowledging this trait is the first step on the road to changing it.” Dr Sharma said in a statement yesterday that GOSH had already taken steps to improve its culture and systems, appointing patient safety educators and patient safety leads in each directorate. Read full story (paywalled) Source: HSJ, 7 July 2022 -
Content ArticlePretty soon there won’t be a trust without an associate director or even board level director fully dedicated to all things equality, diversity and inclusion; relatively new senior roles that must have a purpose, job description and performance indicators. They will spend energy on yet more strategies, start from the top and hope something trickles down. Or they could start where the work is done, and build the tools to make equality, diversity and inclusion (EDI) everyone’s responsibility. Trusts are full of people passionate about EDI. So many roles, so many champions. They meet, share stories, and champion the importance of EDI. All this busyness typically outside a governed frame without the necessary reporting, investigating, actions, outcomes, learning, and measurable improvement. To normalise EDI and make it everyone’s responsibility will involve enabling reporting of EDI incidents, investigating it, taking action, and learning from it, writes Dr Nadeem Moghal in an article for HSJ.
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Event
Learning from patient safety incidents
Patient Safety Learning posted an event in Community Calendar
This 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 2021. Key learning objectives: Understand the new patient safety landscape Understand the need for proportionality of investigation Learn how to use a range of techniques for conducting PSIIs Understand how to write an impactful improvement plan Consider how your current approach to patient safety investigations compares to the agreed national standards Understand typical pitfalls and traps associated with this wider workstream and tips for avoiding them. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. They have also authored articles on significant event analysis and clinical audit/quality improvement, all techniques seen as increasingly relevant to improving patient safety. Register -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Claire talks to us about her role as a Patient Safety Lead and why she thinks the new Patient Safety Incident Response Framework will make her work more practical and patient-centred. She also describes why she set up the Patient Safety Management Network and highlights why patient safety roles would benefit from more standardisation across trusts.- Posted
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Content Article
In a series of blogs, Gina Winter-Bates, Associate Nurse Director Quality and Safety at Solent NHS Trust, shares her experience of implementing Safety Chats. In this final blog of the series, Gina shares the next steps for Safety Chats in her Trust and how they will be building more ways of supporting staff to discuss safety, to seek advice and support, and to receive clear assistance when things have gone wrong. -
EventThis conference focuses on investigating and learning from deaths in the community/primary care. The conference focuses on the extension of the Medical Examiner role to cover deaths occurring in the community and the role of the GP in working with the Medical Examiner to learn from deaths and to identify constructive learning to improve care for patients. The conference will also focus on implementation of the new Patient Safety Incident Response Framework and learning from a primary care early adopter. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-of-deaths-community or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LearningfromdeathsPC
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EventThis one day masterclass will focus on a toolkit to allow organisations to use patient experience and incident to improve patient safety. The Toolkit uses 3 phases: planning, implementation and review. The Francis Report showed that the NHS had stopped listening to the needs of its users. Patient experience is still an underutilised tool in the armoury of a healthcare organisation and commissioners. The toolkit uses the priorities of the Francis Report to improve patient experience and patient safety. These include putting patients first, openness, candour, accountability, complaints handling, culture of caring and compassionate leadership. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/patient-experience-and-learning-from-incidents-to-improve-safety or email aman@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
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EventNote: this conference has been rescheduled from the 14 September 2022. 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. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts and will reflect on learning from deaths. There will be a focus on mortality review during the Covid pandemic and how mortality investigation should be managed in these cases. 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 update delegates on the New National Patient Safety Incident Response Framework including sharing experience from an early adopter site. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-and-learning-from-deaths-in-nhs-trusts or email nicki@hc-uk.org.uk hub members can receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LFDNHS
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News Article
Hundreds of stillbirths wrongly certified as 'unexplained'
Patient Safety Learning posted a news article in News
More than 80% of UK medical certificates recording stillbirths contain errors, research reveals. More than half the inaccurate certificates contained a significant error that could cause medical staff to misinterpret what had happened. The study, published in the International Journal of Epidemiology, also shows that three out of four stillbirths certified as having an "unknown cause of death" could, in fact, be explained. A team from the Universities of Edinburgh and Manchester examined more than 1,120 medical certificates of stillbirths, which were issued at 76 UK obstetric units in 2018. Of the 421 which were resolved, 195 were re-designated as foetal growth restriction (FGR), and 184 as placental insufficiency. Dr Michael Rimmer, clinical research fellow at Edinburgh University’s MRC Centre for Reproductive Health, said: “This study shows some medical certificates of stillbirths contain significant errors. "Reducing these errors and accurately recording contributing factors to a stillbirth is important in shaping research and health policies aimed at reducing the number of stillbirths. Read full story Source: The Herald, 21 June 2022 -
Content ArticleThe Medical Certificate of Stillbirth (MCS) records data about a baby’s death after 24 weeks of gestation but before birth. Major errors that could alter interpretation of the MCS were widespread in two UK-based regional studies. A multicentre evaluation was conducted, examining MCS issued 1 January 2018 to 31 December 2018 in 76 UK obstetric units. A systematic case-note review of stillbirths was conducted by Obstetric and Gynaecology trainees, generating individual ‘ideal MCSs’ and comparing these to the actual MCS issued. Anonymized central data analysis described rates and types of error, agreement and factors associated with major errors. The study demonstrates widespread major errors in MCS completion across the UK. MCS should only be completed following structured case-note review, with particular attention on the fetal growth trajectory. Correct stillbirth cause classification is crucial for families and society; when ‘unexplained’, conditions’ true perinatal mortality contributions are uncounted and preventative strategies cannot be appropriately targeted.
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Content ArticleBenjamin King lived 5-days before parents, Jamie Thomas King and Tamara Podemski, had to pull him off life support. Benjamin's parents share their experience, the value of sharing their story with the media and what changes have happened in UK hospitals since to ensure this won't happen to any other family. The panel discusses the role of human factors and system design and how it can be embraced to ramp up patient safety improvement. Human factors experts across healthcare and aviation will discuss this issue alongside patient advocates who have lost loved ones where the application of principles and methodologies of human factors engineering may have saved their loved ones lives. Hear from the leadership at Christus Muguerza Hospital Sur in Monterrey, Mexico, about their work to become an HRO Champion.
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Content Article
Safety Chats: Part 3 - Starting the conversation
Gina Winter-Bates posted an article in Good practice
In a series of blogs, Gina Winter-Bates, Associate Nurse Director Quality and Safety at Solent NHS Trust, shares her experience of implementing Safety Chats. In Part 3, Gina shares with us how the Safety Chats were conducted and the key themes that came out of them, and what empowers and blocks staff in improving safety. -
Content ArticleSerious incidents not only have a considerable human impact, but they are also detrimental to NHS reputations and finances. The current Serious Incident Framework (SIF) is a reactive, bureaucratic process, where opportunities to reduce the recurrence of a harmful incidence is often missed. With a ‘Get It Right First Time’ mentality, the new PSIRF framework was road-tested by a number of nationally appointed ‘early adopter’ Trusts and commissioners working to implement it during the course of 2021. Now a wider implementation across the NHS is planned, starting spring 2022, with guidance informed by the early adopter pilots. This blog was written by Sian Williams, NHS Team Lead & Managing Consultant, and Paul Binyon, who in a recent assignment has worked with an NHS Trust contributing to an early adopter PSIRF pilot rollout.
