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Showing results for tags 'Organisational learning'.
Found 539 results
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News Article
Bereaved call for body to enforce coroners’ advice
Patient Safety Learning posted a news article in News
Relatives of a teenage rape survivor who died after failures by mental health services are joining other families to demand a new body to enforce coroners’ recommendations to prevent future deaths. Campaigners claim the failure to act on hundreds of coroners’ recommendations every year, and to learn from the findings of often expensive inquiries into disasters, means the same mistakes are being repeated. Gaia Pope, 19, was diagnosed with post-traumatic stress disorder after revealing that she had been drugged and raped when she was 16. She was found dead in undergrowth on a cliff 11 days after disappearing in Swanage, Dorset, in 2017. After one of the longest inquests in legal history, the coroner, Rachael Griffin, made multiple reports last year to authorities including the NHS and police to prevent future deaths, but Pope’s family says most have not been acted upon. The Inquest campaign, which works with families bereaved by state-related deaths, is calling for a “national oversight mechanism” to collate recommendations and responses in a new national database, analyse responses from public bodies, follow up on progress and share common findings. Read full story (paywalled) Source: The Times, 27 June 2023 -
News Article
New approach to safety incidents will see fewer investigations
Patient Safety Learning posted a news article in News
Major reforms have been set out on how NHS organisations should respond to patient safety incidents, which are aimed at ensuring better engagement with patients and families. The Patient Safety Incident Response Framework (PSIRF), published today, replaces the serious incident framework and provides guidance to trusts on how and when they should conduct investigations. According to NHSE, a key aim is to allow trusts to focus resources on where investigations will have the greatest impact, rather than investigating all incidents as they did under the old framework. NHSE said the more flexible approach should make it easier to address concerns specific to health inequalities, as incidents can be learnt from that would not have met the serious incident definition. However, it does not affect the need for a patient safety incident investigation following a never event’ or maternity incident; this is still required. Helen Hughes, chief executive of charity Patient Safety Learning, said the new framework “places an emphasis on individual organisations assessing their patient safety risks”, and provided a “welcome acknowledgement of the importance of engaging patients and families as part of the investigation process”. However, she said there would need to be a “significant training programme for staff in a range of human factors informed approaches”, to ensure reviews lead to safety improvements. She added: “What is being proposed is a complex innovation in the NHS’s approach to incident investigation. Its success to a large part will depend on having the right organisational leadership and resources to support this transition. [NHSE has] now provided a set of tools and a timetable for this. However, ultimately this initiative should be judged on its implementation and effectiveness in reducing avoidable harm.” Read full story (paywalled) Source: HSJ, 16 August 202 -
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 -
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 -
News Article
Regulator clears trust to bring back junior doctors
Patient Safety Learning posted a news article in News
Up to 10 junior doctor posts will be reinstated at a small district general hospital after regulators agreed it had improved its learning environment. In 2021, Health Education England removed 10 doctors from Weston Hospital over concerns they were being left without adequate supervision on understaffed wards. The unusual move prompted University Hospitals Bristol and Weston Foundation Trust to launch a “quality improvement approach” to improve its learner and clinical supervision environment. The regulator said the trust had made significant improvements that included: Better staff engagement with the trust leadership at all levels. Better clinical supervision, particularly around shift handovers and senior oversight of clinical decisions. Better learner experience in new training settings in rheumatology and intensive care medicine. Read full story (paywalled) Source: HSJ, 10 May 2023 -
News Article
Cover-ups and lies in maternity care keep happening, says Donna Ockenden
Patient Safety Learning posted a news article in News
A week after Donna Ockenden published her damning report on the catastrophic failures in maternity services at Shrewsbury and Telford Hospital NHS Trust in March last year, she was contacted by families in Nottingham asking her to investigate how dozens of babies had died or been injured in their city hospitals. Six months later, Ockenden — herself a senior midwife — was put in charge of another inquiry by the government and yet again she is finding a culture of cover-ups and lies in maternity care. “Of the families that I have met in Nottingham to date, some of them have expressed concerns to me that the trust were not truthful in discussions around their cases,” she tells the Times Health Commission. “We have all the systems and structures in place that should be able to spot maternity services in difficulty and here we are again. Families are having to fight to get answers.” The woman who has done more than anyone to highlight the problems with maternity care is reluctant to use the word “crisis” but she warns: “I think that without urgent and rapid action, from central government downwards — on funding and workforce and training — mothers and their babies are not going to be able to receive the safe, personalised maternity care that they deserve and should expect". Read full story (paywalled) Source: The Times, 21 April 2023 -
Content ArticleDr Holly Mincher, Paediatric speciality doctor in training, Somerset NHS Foundation Trust, shares her experience of being involved with Care Opinion. Care Opinion is a website where anyone can share their experience of health or care services, and help make them better for everyone.
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Content ArticleCommunity hospitals are an important part of local health and care systems, yet there has been very little shared on their role and contribution during the pandemic. This project from the Community Hospitals Association sought to redress this and highlight the role of these local hospitals. This two-year project enabled staff to reflect on their experiences and innovations in their community hospitals during the pandemic in a systematic way that facilitated wider sharing and learning. It captures the experiences of staff working in UK community hospitals during the COVID-19 pandemic, with a focus on positive impact changes.
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Content Article
When patients are left to blow the whistle on unsafe care
Steve Turner posted an article in Whistle blowing
This short blog highlights the situations where patients, carers, parents and relatives are failed by healthcare systems and by the leadership. They are left to stand alone against powerful institutions, because when staff speak up and 'blow the whistle' it often results in retaliation. Investigating and resolving the patient safety issue then becomes buried under an employment issue. -
Content ArticleThis summary of how a National Patient Safety Board (NPSB) will benefit patients and families was coproduced by the NPSB Advocacy Board with Patients for Patient Safety US. It outlines how the NPSB would ensure more comprehensive learning from patient safety incidents, ensure patients and families have a core role in governance and priority setting and that data is used to better understand patient safety in the US.
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Content ArticleAgainst the backdrop of the Covid-19 pandemic, ensuring the safety of health and social care services remains a serious, ongoing challenge. This report examines how patient safety governance mechanisms in Organisation for Economic Co-Operation and Development (OECD) countries have withstood the test of Covid-19. It provides recommendations for further improving patient safety governance and strengthening health system resilience in OECD countries. This working paper was produced by the OECD for the 5th Global Ministerial Summit on Patient Safety, held in Montreux, Switzerland in February 2023.
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Content ArticleIn this podcast to support providers with the transition to the Learn from Patient Safety Events (LFPSE) service, the NHS's new national system for the recording and analysis of patient safety events, NHS England talks to Zahra and Mandy, NHS England reporting leads, about the practical steps providers can take to get connected to LFPSE. It covers how to get started, what to do with your old data, the kinds of support available, what transition means for ICBs, and what the Reporting Leads have learned from the process so far.
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Content Article
Safety culture: learning from best practice (15 November 2022)
Patient-Safety-Learning posted an article in Culture
This document outlines NHS England's approach to learning from safety culture best practice. It covers: Safety culture context within the NHS patient safety strategy Leadership Continuous learning and improvement Measurement and systems Teamwork and communication Psychological safety Inclusion, diversity and narrowing healthcare inequalities Case studies -
Content ArticleIn this blog, Judy Walker, an After Action Review (AAR) expert, looks at how effective learning from disasters and incidents can restore hope and trust, offering long-term improvements to systems that have failed. She talks about how public inquiries, although they can seem frustratingly slow, benefit society when the relevant authorities ensure that learning is understood and implemented. She compares this to the impact of AARs, highlighting that people’s trust in the process is linked to their perception of the changes that happen as a result of the AAR. She outlines three steps that NHS providers should take to ensure the AAR process is effective in restoring hope: Highlight to all staff on a regular basis, the benefits that are being delivered due to AARs Ensure patients and family members are provided with specific information about how AARs prevent future harms Support the people who lead AARs to do so skilfully, so that quality is assured and staff can trust in the safety and value of the process.
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Content ArticleThis report considers the number of safety incidents in surgery occurring in the NHS since 2015 and calls for action to improve surgical safety. It also highlights the perceptions of patients from a survey of people who have had surgery in the last five years. It is authored by surgical care platform Proximie, with support from experts in the surgical space.
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Content ArticleIn this blog, Matthew Wain highlights how NHS organisations can support staff with patient safety investigations, and more generally, in the face of increased pressure. He looks at missed learning opportunities, psychological impact, and the support tools and programmes available for staff. Further reading: Patient Safety Learning's Staff Support Guide: a good practice resource following serious patient harm
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Content ArticleIn this article, Roger Kline, Research Fellow at Middlesex University, explains what caused the sinking of the Herald of Free Enterprise ferry. The sinking of the Herald of Free Enterprise on March 6 1987 with the loss of 198 lives was an accident waiting to happen, highlighting the devastating consequences of abandoning safe working practices in the name of financial savings. Human factors science learned from the Herald disaster is widely applied in sectors as diverse as nuclear power stations and healthcare.
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Content ArticleIn this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
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Content ArticleNHS England has recorded two podcasts sharing insight and advice from organisations that have completed the transition from the National Reporting and Learning System (NRLS) to the new Learn from Patient Safety Events (LFPSE).
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Content ArticleIncident reporting is a crucial tool for improving patient safety, alongside an open culture that supports this. In the NHS the new Learn from Patient Safety Events (LFPSE) service is now being rolled out to replace the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS). This article details correspondence between Patient Safety Learning and NHS England in relation to concerns raised by staff about the development and implementation of the LFPSE service
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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 ArticleOn 9 November 2022, The Professional Standards Authority hosted the Safer care for all conference to discuss questions and issues highlighted in the report Safer care for all – solutions from professional regulation and beyond. This webpage contains video summaries of the conference sessions. The conference provided an opportunity to hear experts’ views as well as consider and contest the themes raised in the report, including the PSA's main recommendation, the creation of a health and social care safety commissioner in all four UK countries. Speakers and delegates came from both professional and system regulators as well as patient organisations, the ombudsman, the NHS, health and care sector organisations and major healthcare inquiries.
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Content ArticleThe third leading cause of death in the US is its own healthcare system—medical errors lead to as many as 440,000 preventable deaths every year. To Err Is Human is an in-depth documentary about this silent epidemic and those working quietly behind the scenes to create a new age of patient safety. Through interviews with leaders in healthcare, footage of real-world efforts leading to safer care, and one family’s compelling journey from being victims of medical error to empowerment, the film provides a unique look at the US healthcare system’s ongoing fight against preventable harm.
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Content ArticleThis article in Time reviews the documentary film 'To Err is Human', which explores the tragic outcomes of medical errors and the medical culture that allows them to persist. The film follows the Sheridans, a family from Boise, Idaho on their journey to understand how two major medical errors befell their family: one that contributed to a case of cerebral palsy, and another that involved a delayed cancer diagnosis and ended in death.
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Content ArticleIn this podcast, the Learn from Patient Safety Events (LFPSE) team talks to the National Director for Patient Safety about the new LFPSE service, why it’s important, and the benefits he thinks it will bring for patient safety.
