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Showing results for tags 'Organisational learning'.
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Community PostFabulous conference. Please share your take away actions and start a discussion
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Community Post
Definition of "Lessons Learned"
Haydn Williams posted a topic in Methodology and guidance: How to do an investigation
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I've been searching for a definition of "Lessons Learned", to inform some internal discussion and a policy review. However, I cannot seem to find one anywhere - I've tried as much NHSI and old NPSA documentation as I can get my hands on, Googled some Trust policies, and done some other searches. The closest I can find is some wording on Knowledge for Healthcare: This seems to be a start, but not necessarily specific to incidents and learning from investigations. I'm also keen to use wording from an organisation which already carries a bit of weight and gravitas, rather than developing our own, if possible. Is anyone aware of anything I might have missed?- Posted
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Content Article
It has become fashionable to purge the term ‘error’ from the safety narrative. Instead, we would rather talk about the ‘stuff that goes right’. Unfortunately, this view overlooks the fact that we depend on errors to get things right in the first place. We need to distinguish between an error as an outcome and error as feedback, writes Norman MacLeod in this blog for the hub.- Posted
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Content ArticleNHS Resolution has launched its first eLearning module that focuses on learning from the significant avoidable harm that can occur during antenatal and postnatal care and is seen in the cases notified to its Early Notification Scheme. This free resource is designed to support clinicians working in maternity services. The module uses three illustrative case stories to immerse learners into the antenatal, intrapartum and postnatal care provided to mothers and the neonatal care provided to their babies. It aims to deepen learners' understanding of NHS Resolution’s role within the healthcare system, develop their understanding of the law of negligence as applied to clinical claims and explore how clinical decisions and actions can lead to avoidable harm. The module takes approximately two-and-a-half hours to complete and can be used as evidence of CPD hours undertaken for revalidation.
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Content ArticleGloucestershire Hospitals NHS Foundation Trust introduced a policy for reviewing deaths in 2017 based on the structured judgement review (SJR) methodology, which identified triggers for which deaths to review. To support implementation, the Datix system was modified to report deaths. The new tool required a culture change in how mortality was reviewed and raised concerns regarding responsibilities, workload and resource. This webpage and poster describe the quality improvement process and how these issues were overcome.
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Content Article
In a new report analysing healthcare complaint investigations, the Parliamentary and Health Service Ombudsman (PHSO) have set out the need for the NHS to do more to accept accountability and learn from mistakes in cases of avoidable harm. This blog sets out Patient Safety Learning’s reflections on this report.- Posted
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Content Article
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"I am thirty miles south of London’s Gatwick Airport, the world’s busiest single-runway airport, when one of the seven Flight Control computers in my Airbus A320 aircraft fails . . . ’ So begins this pioneering book by Niall Downey – a cardio-thoracic surgeon who retrained to become a commercial airline pilot – where he uses his expertise in medicine and aviation to explore the critical issue of managing human error. With further examples from business, politics, sport, technology, education and other fields, Downey makes a powerful case that by following some clear guidelines any organisation can greatly reduce the incidence and impact of making serious mistakes. While acknowledging that in our fast-paced world getting things wrong is impossible to avoid completely, Downey offers a strategy based on current best practice that can make a massive difference. He concludes with an aviation-style Safety Management System that can be hugely helpful in preventing avoidable catastrophes from occurring. -
Content ArticleThere have been significant developments in patient safety over the last decade. But there is a concerning disconnect between increasing activity and progress made to embed a just and learning culture across the NHS. Recognising the challenging operational context for the NHS, this report from the Parliamentary and Health Service Ombudsman (PHSO) draws on findings from their investigations. It asks what more must be done to close the gap between ambitious patient safety objectives and the reality of frontline practice. PHSO identified 22 NHS complaint investigations closed over the past three years where they found a death was – more likely that not – avoidable. It analysed these cases for common themes and conducted in-depth interviews with the families involved.
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Adverse incidents arising from suboptimal healthcare are a major cause of worldwide morbidity and mortality. Arriving at an understanding of the conditions under which adverse incidents occur has the potential to improve the safety of healthcare provision. Staff working in the NHS have been contributing their experiences via a narrative data capture platform – SenseMaker – to help gain contextual insights on a wide range of topics under exploration by the NHS Horizons team. This blog by Rosanna Hunt (Senior Associate, NHS Horizons) in collaboration with Lizzy MacNamara (Junior Research Consultant, The Cynefin Co.) and Taj Nathan (Consultant Forensic Psychiatrist, Cheshire & the Wirral Partnership Foundation Trust) describes how the SenseMaker® platform could be used to extract staff experiences on the topic of patient safety incidents both reported and unreported by staff, and the facilitated conversations that would be needed to transform the data into actionable insights and commitment to change. -
Content ArticleThis report highlights the failure to learn from preventable state related deaths in the UK. It focuses on concerns around the implementation of recommendations following inquests, public inquiries, investigations and official reviews, calling for the creation of a new independent public body, a National Oversight Mechanism, to address this. The report was launched as part of the ‘No more deaths’ campaign by Inquest, an independent charity combining specialist support for bereaved people following a state related death with campaigning for justice and change.
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Content ArticleA hot briefing template for the purpose of sharing lessons learned across Scotland particularly for rare or unusual events.
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Content ArticleA key benefit of the new Learn from Patient Safety Events (LFPSE) service is its introduction of machine learning to hugely enhance the NHS’s capabilities for processing and analysing records of patient safety events. This podcast discusses how we plan to introduce machine learning in LFPSE, how this will support the NHS to improve patient safety, what changes staff will see as a result, our longer-term ambitions, and how providers can get involved in shaping this exciting new revolution in patient safety learning.
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Content ArticleThe Royal United Hospital Bath NHS Trust project tested different ways to communicate with staff about patient safety, to encourage the reporting of incidents and to promote a learning culture.
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Content ArticleLearn from Patient Safety Events (LFPSE) presentation from Southern Health NHS Foundation Trust.
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Content ArticleIn the first in a series of blogs looking at the range of investigation methods used by HSIB, Nichola Crust reflects on how Appreciative Inquiry can be used to examine patient safety and identify opportunities for learning.
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Content ArticleWith increasing concerns around the working conditions and psychological wellbeing of staff in the NHS, questions have been raised about how best to support staff wellbeing. Research is clear that wellbeing interventions that target the organisation and staff’s working environment work better than those which focus solely on supporting the individual person. Although it might seem simple to say: “we need to improve working conditions”, the challenge is whether this is possible and, if so, what this actually looks like in practice.
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Content ArticleSignificant Event Audit (SEA) ensures that primary care teams learn from patient safety incidents and ‘near misses’ by highlighting both strengths and weaknesses in the care provided. This guidance from the Royal College of General Practitioners (RCGP) aims to enable primary care teams to conduct an effective SEA with the aim of improving care for all patients.
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Content ArticleIn this blog, After Action Review (AAR) specialist Judy Walker shares an account of a successful AAR that took place amongst a surgical team. The AAR was called after a near-miss where the anaesthetist was prevented from injecting spinal block medication into the wrong side of a patient's spine by an operating department practitioner (ODP). The story demonstrates the benefits of AAR, including accelerated learning, a no-blame approach, flattening staff hierarchy and a significant reduction in the time it takes to investigate an incident.
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Content ArticleIn 2002, a dedicated group from Pennsylvania passed the Medical Care Availability and Reduction of Error (MCARE) Act, the most robust state-level legislation of its kind. Its legacy remains 21 years later. In this interview with the journal Patient Safety, Pennsylvania's Patient Safety Authority chair, Dr Nirmal Joshi, discusses ways care has improved, what challenges persist, and how to achieve the unachievable—true culture change.
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Content ArticleThe NHS is at a critical juncture in its 75-year history. With finances as tight as they have ever been, and a workforce stretched to breaking point due in part to spiralling demand from an older and sicker population and a shrinking labour pool, it is clear that things cannot carry on as they are. The time has come to think and act differently – at every level of the health and social care system – and to do so at pace. This long read describes five guiding principles that should inform implementing the NHS Impact approach to improvement at provider, ICS and national level to maximise the chances of success in the current climate. We also present recommendations for provider organisation, system and national leaders on the steps needed to translate these principles into sustained improvements across ICSs.
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Content ArticleRecently, there has been a concerning increase in the number of deaths of pregnant women, especially from Black, Asian and deprived backgrounds. In addition, there have been several investigations into safety issues in maternity services, such as the Ockenden, East Kent, and Shrewsbury and Telford report. This National Institute for Health and Care Research (NIHR) Collection highlights evidence in priority areas, identified in the East Kent report, to support high-quality care and avoid safety issues in maternity services.
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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. Stephen talks to us about his time as turnaround Chair of Mid Staffordshire NHS Foundation Trust, how NHS boards can ensure they live their values and why creating a safe space to share concerns improves patient safety. -
Content ArticleThe implementation and continuous improvement of patient safety learning systems (PSLS) is a principal strategy for mitigating preventable harm to patients. Although substantial efforts have sought to improve these systems, there is a need to more comprehensively understand critical success factors. This study aims to summarise the barriers and facilitators perceived by hospital staff and physicians to influence the reporting, analysis, learning and feedback within PSLS in hospitals.
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Content ArticleIn this letter to The Lancet, Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations argues that the need to focus on equitable rollout of vaccines in the event of a future pandemic is a key global health priority. He proposes that Governments, pharma companies and other stakeholders should focus on the challenges that led to the inequitable rollout of vaccines, which he identifies as vaccine nationalism and need for more diverse manufacturing. He highlights an industry proposal for equitable response to future pandemics supported by vaccine manufacturers and biotechnologies. the proposal involves manufacturers setting aside a percentage of pandemic tools for allocation to susceptible populations in low-income countries.
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Content ArticleJudy Walker summarises four tools that can be used for the Patient Safety Incident Response Framework (PSIRF), explaining what they are and the strengths and weaknesses of each: SWARM Huddle MDT Review After Action Review Patient Safety Incident Investigation (PSII).
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