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Found 224 results
  1. Content Article
    What can you learn from the Nimrod disaster? At a superficial level, the specifics of this event were unique, but by delving deeper into the ‘why?’, the Review team revealed that history does in fact repeat itself. Nimrod XV230: Parallels with healthcare. By discussing the relevance of the Nimrod XV230 event to healthcare, Martin aims to illustrate that the organisational lessons from this event are applicable to almost any industry. There are parallels with several major healthcare events. Success, complacency and failure. The track record of the Nimrod aircraft led to a high level
  2. Content Article
    The report highlights the next steps that maternity services and the CQC need to take: For maternity services and local maternity systems Leadership: In line with essential action 2 of the first Ockenden review, Boards must take effective ownership of the safety of maternity services. This includes ensuring that they have high quality, multidisciplinary leadership and positive learning cultures. They must seek assurance that staff feel free to raise concerns, that their concerns and adverse events lead to learning and improvement and that individual maternity staff competencies ar
  3. Content Article
    Findings: The strong associations between organizational readiness to change and safety climate in nursing homes have the following implications for practice and research: Safety climate interventions should first assess and address staff and system readiness to change. Readiness to change assessments and safety climate interventions may also need repeating as staff turnover brings in new staff and may change these dynamics. Whether staff skills and knowledge moderate the association of readiness to change and safety climate should also be examined in future research.
  4. Event
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    When things go wrong in health and social care, there can be significant consequences for patients, staff, and leaders. But, too often, the voices of people who use services and their families have gone unheard, while staff have feared being blamed for mistakes that result from systemic failings or human error. So how can health and social care leaders at all levels create a just culture, where mistakes lead to learning? And how can organisations take accountability for learning and improving after something goes wrong? The King’s Fund is co-hosting this virtual conference in partner
  5. Content Article
    The key topics covered in this video are as follows: What is human factors/ergonomics and how does it relate to healthcare? (at 2 mins and 20 secs) What is the value of high reliability to healthcare? (at 9 mins and 20 secs) How can patient insights and contributions help to create more highly reliable organisations? (at 17 mins and 40 secs) Reflections on the impact of culture and barriers pose to increasing resilience and learning from safety. (at 20 mins and 45 secs) The role of ‘speaking up’ initiatives. (at 25 mins and 40 secs) Incident reporting and th
  6. Content Article
    The report sets out several recommendations including: 1.Improve the engagement of parents in reviews by standardising and resourcing local processes to ensure all bereaved parents are told a review will take place and have ample opportunities at different stages to discuss their views, ask questions and express any concerns as well as positive feedback they have about the care they received. Action: Trusts and Health Boards, staff caring for bereaved parents 2.Provide adequate resourcing of multidisciplinary PMRT review teams, including administrative support. Action: Trus
  7. Content Article
    Related content in this series Introductory blog: Improving patient safety through high reliability Video conversation: The importance of culture in achieving high reliability in healthcare
  8. Content Article
    This research presents a number of factors contributing to poor reporting in healthcare as well as suggestions for system improvement drawn from the car industry. Amongst these, an increase in specificity of reporting method, need for long term data and recognition of behavioural differences between different sources could lead to better reporting methods and potentially reduce existing levels of underreporting. It also considers that bringing device performance reporting outside the context of incidents only would lead to improved knowledge and learning for all stakeholders. Thus, a diff
  9. Content Article
    Background In 2018, SIM was selected for national scaling and spread across the Academic Health Science Networks (AHSNs). The High Intensity Network (HIN) has been working with the three south London Secondary Mental Health Trusts: The South London and Maudsley NHS Foundation Trust, Oxleas NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust, and the Metropolitan Police, London Ambulance Service, A&E, CCG commissioners, and the innovator and Network Director of the High Intensity Network. The model can be summarised as: A more integrated, infor
  10. Content Article
    Let’s start with a story I was once told… There once was a very successful farmer who hired many people to work on his farm; at a glance, you could see countless heads of men and women tilling the ground. He grew very rich. The wealthier he became the more people he hired. His farmland kept increasing every year until it got to the boundary of a river. Although there were many workers, the farmer knew everyone by name and was able to account for them on a daily basis. However, over time, he noticed some workers who came to work could not be accounted for – they went missing. The farme
  11. Content Article
    The Coroner notes that, although he was assessed at home by the midwifery team at aged 5 days, no basic observation assessments were taken, such as temperature, heart rate and respiration rate, from the deceased or his mother to confirm their wellbeing. There is no national guidance for such checks, however, University Hospital Dorset NHS Foundation Trust (UHD) have since changed their local policies to embed better safety nets. The local policy now provides guidance that at each visit up to day 10 post birth, a full set of baby and maternal observations are to be taken. The Coroner also
  12. News Article
    Thousands of similar errors contributing to patient deaths are being repeated by hospitals despite warnings from coroners, according to new research. An analysis of four years of official reports by coroners, issued after the conclusion of inquests into patient deaths, has revealed the impact of the NHS struggling with a lack of resources and staff. Coroners found similar mistakes across hundreds of inquests. Professor Alison Leary, chair of healthcare a workforce modelling at London South Bank University, and who led the study, told The Independent: “We are missing opportunities to
  13. Content Article
    The aim of this study from Leary et al. was to examine the feasibility of extracting data from these reports and to evaluate if learning was possible from any common themes. In total 710 reports were examined, with 3469 concerns being raised. Thirty-six reports expressed concern about having to issue repeat PFDs to the same organisation for the same or similar concerns. Thematic analysis reliability was high (κ 0.89 unweighted) with five emerging primary themes: deficit in skill or knowledge, missed, delayed or uncoordinated care, communication and cultural issues, systems issues and lack
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