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Showing results for tags 'Organisational learning'.
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Content ArticleRisk managers and the insurers with whom we work have the greatest opportunity in healthcare today to improve patient safety. Our most egregious mistakes become medical malpractice claims and lawsuits. Some of these go to trial where the outcome is public; however, the least defensible cases are settled without a trial. Almost every settlement includes a confidentiality or nondisclosure clause (NDC). Such clauses become “gag orders.” Providers who could learn from the mistake of a colleague do not, and the same mistake is repeated, often many times over. The stories of these settlements are a rich source of learning, and it’s time to tell them—anonymously. No naming names, no disclosure of settlement amounts, no “blame and shame.” Stories are powerful, attention-grabbing, and memorable. Telling them is a unique opportunity to link the prevention of patient harm to the healing mission of healthcare and acknowledge the common wish of every plaintiff that “this won’t happen to someone else.”
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Content ArticleThe Piper Alpha exploded and sank on 6 July 1988, killing 165 of the men on board. Some of the lessons learned from the inquiry into the Piper Alpha Disaster could be applied to healthcare.
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Content ArticleTo provide high quality services in increasingly complex, constantly changing circumstances, healthcare organisations worldwide need a high level of resilience, to adapt and respond to challenges and changes at all system levels. For healthcare organisations to strengthen their resilience, a significant level of continuous learning is required. Given the interdependence required amongst healthcare professionals and stakeholders when providing healthcare, this learning needs to be collaborative, as a prerequisite to operationalising resilience in healthcare. As particular elements of collaborative working, and learning are likely to promote resilience, there is a need to explore the underlying collaborative learning mechanisms and how and why collaborations occur during adaptations and responses. The aim of this study from Haraldseid-Driftland et al. was to describe collaborative learning processes in relation to resilient healthcare based on an investigation of narratives developed from studies representing diverse healthcare contexts and levels.
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Content ArticleIn this blog, Ian Lavery, Senior Investigation Science Educator at the Healthcare Safety Investigation Branch (HSIB) summarises a presentation given to HSIB staff by healthcare improvement expert Professor Mary Dixon-Woods. The presentation highlighted that a recommendation alone could fall short of the intended impact on the healthcare system. It looked at creating recommendations to respond to real world working, the importance of involving people most affected by patient safety incidents and why it's vital to look at when things go right.
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Copy of the speech from Helen Hughes, Chief Executive of Patient Safety Learning, given at the Professional Standards Authority for Health and Social Care (PSA) Parliamentary launch of the publication 'Safer care for all - Solutions from professional regulation and beyond'. -
Content ArticleReducing errors in diagnosis is the next big challenge for patient safety. This article highlights ways in which healthcare organisations can pursue learning and exploration of diagnostic excellence (LEDE). Building on current evidence and their recent experiences in developing such a learning organisation at Geisinger in Pennsylvania, the authors propose a 5-point action plan and corresponding policy levers to support the development of LEDE organisations.
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Content ArticleSorrel King was a 32-year-old mother of four when her eighteen-month-old daughter, Josie, was horribly burned by water from a faulty water heater in the family's new Baltimore home. She was taken to Johns Hopkins--renowned as one of the best hospitals in the world--and Sorrel stayed in the hospital with Josie day-in and day-out until she had almost completely recovered. Just before her discharge, however, she was erroneously injected with methadone, and died soon after. Sorrel's account of her unlikely path from grieving parent to nationally renowned advocate is interwoven with descriptions of her and her family's slow but steady road to recovery, and ends with a deeply affecting description of a ski trip they took recently. The sun is shining, her children are healthy, and they are all profoundly happy--a condition that Sorrel has learned to appreciate all the more for Josie. The book ends with a resource guide for patients, their families, and healthcare providers; it includes information about how to best manage a hospital stay and how to handle a medical error if one does occur.
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Content ArticleOn 3 September 2021 assistant coroner Jonathan Stevens commenced an investigation into the death of Martha Mills, aged 13 years. Martha sustained a handlebar injury whilst cycling on a family holiday in Wales. She was transferred to King’s College Hospital London and died approximately one month later. Her medical cause of death was: 1a refractory shock 1b sepsis 1c pancreatic transection (operated) 1d abdominal trauma.
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Content ArticleSharing her story in the Guardian, Merope gives a heart breaking account of how her daughter, Martha Mills, was allowed to die, but also what happens when you have blind faith in doctors – and learn too late what you should have known to save your child’s life.
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This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on 26 August 2022. The discussion considered the use of two different system-based approaches for learning from patient safety incidents recommended by the NHS Patient Safety Incident Response Framework (PSIRF). The PSMN is an informal voluntary network for patient safety managers. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance, offer peer support and create a safe space for discussion. You can find out more about the network here -
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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. Soojin talks to us about how her personal experience of harm motivated her to work in healthcare and campaign for patient safety, the power of collaboration in improving healthcare safety and how healthcare workers can take steps to improve their own patient interactions. -
Content ArticleOnline patient feedback is becoming increasingly prevalent on an international scale. However, limited research has explored how healthcare organisations implement such feedback. This research from Baines et al. sought to explore how an acute hospital, recently placed into ‘special measures’ by a regulatory body implemented online feedback to support its improvement journey.
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Content ArticleSafety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organsation. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value.
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Content ArticleWelcome to the being better together podcast, from Learning from Excellence and Civility Saves Lives. This podcast from Learning from Excellence and Civility Saves Lives is a series of conversations with people who inspire us, about making healthcare a better place to work. It covers a wealth of topics, from workplace cultures, through inspiration, laughter and joy, to appreciative inquiry and how do work safely.
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Content ArticleHistorical and current methodologies in patient safety are based on a deficit-based model, defining safety as the absence of harm. This model is aligned with the human innate negativity bias and the general philosophy of health care: to diagnose and cure illness and to relieve suffering. While this approach has underpinned measurable progress in healthcare outcomes, a common narrative in the healthcare literature indicates that this progress is stalling or slowing. It is important to learn from and improve poor outcomes, but the deficit-based approach has some theoretical limitations.
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Content ArticleThe purpose of the Learn from patient safety events (LFPSE) service (previously known during development as the Patient Safety Incident Management System - PSIMS) is to enable learning from patient safety events – incidents, risks, outcomes of concern and also things that went well. Our ability to protect future patients from harm depends on promoting a culture that welcomes and encourages the recording of events. It is essential to abide by these principles to ensure that we continue to successfully learn from patient safety events and reduce harm. This document sets out the circumstances in which LFPSE data are the appropriate data source to be used and describes their appropriate use. These principles emphasise the purpose and characteristics of LFPSE data, and promote consistency across data users. It is essential that users of LFPSE data understand and represent it appropriately, as inappropriate presentations of LFPSE data could discourage recording.
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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 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 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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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 ArticleEngaging with company executives over how their decisions affect employees’ performance further down the line could help improve safety at sea. An 18-month study found investigations of maritime accidents tend to “blame the ship”, often resulting in the punishment of seafarers. Authors Barry Kirwan, Ben Wood and Beatrice Bettignies-Thiebaux of Eurocontrol, argue that this approach hampers learning and more attention needs to be paid to contributory factors from higher up the chain. They say that a deeper understanding of organisational influences and how company culture contributes to accidents will help promote safety across the business and better address problems. They have developed a ‘Reverse Swiss Cheese Maritime Model’ which moves from organisation through design and fleet support to vessel operations. To facilitate this, they believe there needs to be greater engagement between analysts and the industry’s decision makers and are hoping to trial their approach with several organisations over the next year. Barry, who presented the findings at our recent conference, said: “We need to look not only at how ‘work is done’ but how ‘business is done’.”
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Content ArticleHow can NHS provider organisations and systems reliably and sustainably improve care? Historically, most improvement interventions have been discrete, small-scale efforts run by individual teams, often without reference to what else is taking place in their trust. However, it is now widely accepted that a patchwork of local interventions is unlikely to deliver sustained improvement or efficiencies on the scale that policymakers and local leaders want. This report by the Health Foundation outlines learning from the evaluation of the NHS partnership with Virginia Mason Institute, which examined how five NHS trusts in England attempted to build a culture of continuous improvement.
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Content ArticleThe Patient safety incident response framework (PSIRF) represents a new approach to responding to incidents. Under PSIRF, those leading the patient safety agenda within provider organisations, together with internal and external stakeholders (including patient safety partners, commissioners, NHS England, regulators, Local Healthwatch, coroners etc), decide how to respond to patient safety incidents based on the need to generate insight to inform safety improvement where it matters most. Key issues must first be identified and described as part of planning activities before an organisation agrees how it intends to respond to maximise learning and improvement. This guidance has been developed collaboratively between Stop the Pressure Programme, National Wound Care Strategy leads and members of the Patient Safety Team, with the support from the Patient Safety Incident Response Framework (PSIRF) Implementation and Working Groups.
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Published on 19 October 2022, the report of the investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. The investigation found that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed. In this article, Patient Safety Learning analyses the findings of this report from a broad patient safety perspective, focusing on five key themes that are consistent with many other serious patient safety inquiries and reports in recent years. It sets these in their wider context and highlights the need for a fundamental transformation in our approach to patient safety if similar scandals are to be prevented in the future.- Posted
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Content ArticleThis article in the HSJ explores the challenges in implementing the Patient Safety Incident Response Framework (PSIRF) and looks at how it will help achieve effective learning and improvement. Liz Hackett, health advisory partner at Hempsons law firm, addresses the following questions: Who does PSIRF apply to? How does PSIRF help achieve effective learning and improvement? What is required? Involving patient safety and addressing inequalities The challenge
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