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Showing results for tags 'Organisational learning'.
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Content Article
CORESS reports
Patient Safety Learning posted an article in Surgery
CORESS is an independent charity, which aims to promote safety in surgical practice in the NHS and the private sector. CORESS receives confidential incident reports from surgeons and theatre staff. These reports are analysed by the Advisory Board, who make comments and extract lessons to be learned. Aiming to educate, and avoid blame, CORESS calls on surgeons to recognise a near miss or adverse event, react by taking action to stop it happening and then report the incident to CORESS so that the lessons can be published. Every month CORESS highlight's one of the cases reported for you to consider the issues raised and read the experts comments.- Posted
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- Surgery - General
- Patient safety incident
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Content ArticleHealthcare professionals have a duty to be open and honest with patients and people in their care when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This is know as the professional duty of candour. This joint guidance from the General Medical Council and Nursing & Midwifery Council provides detailed guidance for healthcare professionals on: being open and honest with patients in your care, and those close to them, when things go wrong. encouraging a learning culture by reporting errors.
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- Nurse
- Duty of Candour
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Content Article
Learning from Coroner's reports
Patient Safety Learning posted an article in Coroner reports
When a patient dies because of preventable avoidable harm it is crucial that we learn from the event and implement changes to ensure it does not reoccur. Implementing the findings and recommendations of Coroner’s Prevention of Future Deaths (PFD) reports can play a key role in this. This blog reflects on a recent discussion at a Patient Safety Management Network (PSMN) meeting about PFD reports and how their insights can be used for learning and improvement. The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. You can find out about the network here.- Posted
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- Coroner reports
- Coroner
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Content ArticleNHS England’s Patient Safety Team will be launching the new Patient Safety Incident Response Framework (PSIRF) in the Spring of 2022, and one of the tools it will recommend to enhance learning from events is After Action Review (AAR). It is likely that each healthcare provider will define its own 'playing field' for AAR as the PSIRF is integrated in daily practice in the months and years ahead, yet this can extend far wider than many assume. In the 12 years since I was trained as an AAR Conductor, I have grown to appreciate its adaptability as well as the many benefits it delivers. The examples of real AARs described here are designed to illustrate some of the many applications. As you will see, these AARs have created opportunities for learning at three levels, all of which contribute to the delivery of safe and effective patient care: the individual, the team and the organisation.
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- Patient safety strategy
- Training
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Content ArticleThis is the report of an independent assurance review of an independent investigation which considered the care and treatment of mental health service user Mr A in Greater Manchester, which was published in 2020.
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- Mental health
- Organisational learning
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Content ArticleThis is the third in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Deinniol tells us about how his role at the Healthcare Safety Investigation Branch (HSIB) helps make healthcare services in the UK safer for both patients and staff. He explains the importance of understanding the complexity of healthcare systems and the pressures that staff within the NHS face. He highlights the need build trust with patients, staff and other stakeholders to find ways forward in improving patient safety.
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- Investigation
- Patient engagement
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Content Article
Crossword counterpoint: glimpses of NHS whistleblowing terrain
Hugh Wilkins posted an article in Whistle blowing
This blog is prompted by a recent newspaper crossword in which one of the clues, quadruplicated, was 'Whistle-blower'. The four answers were, respectively, 'canary', 'snitch', 'telltale' and 'betrayer'. The blog draws attention to negative perceptions of whistleblowers in the eyes of some people. It emphasises how wrong these perceptions are and how damaging this can be, with serious patient safety implications. In this blog I provide a crossword counterpoint (attached below to solve), which seeks to support learning about the realities of hostility against some staff who speak up in the NHS. I will share a follow-up blog which contains the solution to this crossword and seeks to provide further education on this topic where there is so much confusion and misunderstanding.- Posted
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- Whistleblowing
- Speaking up
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Content ArticlePromoting a ‘just culture’ is a key theme in patient safety research and policy, reflecting a growing understanding that patients, their families and healthcare staff involved in safety events can experience feelings of sadness, guilt and anger, and need to be treated fairly and sensitively. There is also growing recognition that a ‘blame culture’ discourages openness and learning. However, there are still significant difficulties in listening to and involving patients and families in organisations' responses to safety incidents, and for healthcare staff, a blame culture often persists. This can lead to a sense of sustained unfairness, unresponsiveness and secondary harm. The authors of this article in BMJ Quality & Safety argue that confusion about safety cultures comes in part from a lack of focused attention on the nature and implications of justice in the field of patient safety. They make suggestions about how to open up a conversation about justice in research and practice.
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- Just Culture
- Research
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Content Article
Blog - Learning from HSIB Covid-19 reports (27 January 2022)
Patient-Safety-Learning posted an article in Blogs
This blog summarises investigations about Covid-19 and its impact on the healthcare system carried out by the Healthcare Safety Investigation Branch (HSIB). It highlights learning from five HSIB reports: COVID-19 transmission in hospitals: management of the risk – a prospective safety investigation Early warning scores to detect deterioration in COVID-19 inpatients Oxygen issues during the COVID-19 pandemic Treating COVID-19 patients using continuous positive airway pressure (CPAP) Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response- Posted
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- Organisational learning
- Pandemic
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Content ArticleHealthcare is recognised as a high-risk industry, involving complex systems, vulnerable individuals, and constantly evolving clinical treatments and healthcare products. This is the recording of a webinar hosted by NHS Supply Chain which looked at key patient safety issues in the NHS. It includes examples of learning related to patient safety and assurance priorities for safe healthcare products and services. Speaker panel: Helen Hughes, Chief Executive of Patient Safety Learning Tracey Cammish, NHS Supply Chain Heather Tierney-Moore OBE, NHS Supply Chain Dave Fassam, Healthcare Safety Investigation Branch (HSIB)
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- Patient engagement
- Long waiting list
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Content ArticleThis dissertation from Ivan Pupulidy, Tilburg University, introduces a network of practices that transformed the United States Department of Agriculture (USDA) Forest Service accident investigation. This dissertation uses case studies to show the interweaving of organisational and individual journeys, each of which began with the strength to inquire and to challenge assumptions. The case studies show how constructed realities, including my own, were challenged through inquiry and how four practices emerged that supported sense making at both the field and organisational leadership levels of the organisation.
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- Investigation
- Methodology
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Content ArticleIn this blog Patient Safety Learning provides an overview of the key points included in its response to the call for evidence for the Health and Social Care Select Committee Inquiry examining the case for reform of NHS litigation.
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- Negligence claim
- Legal issue
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Content ArticleTwo years ago, a patient safety incident at North Bristol Trust led to the introduction of Swarm – a step change in how the trust responds to safety incidents. Swarm is a form of safety incident huddle that takes place as close as possible in time and place to the incident, allows blame-free investigation and leads to prompt action. This article describes how Swarm works, its advantages over root cause analysis, and how it is being embedded in the safety culture of North Bristol Trust.
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- Patient safety incident
- Investigation
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Content ArticleJudy Walker, iTS Leadership, presented at the recent Patient Safety Management Network drop-in session on After Action Reviews. View the presentation below.
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- After action review
- Organisational learning
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Content ArticleHarm reviews give assurance to patients, patient groups, commissioners and the public as to whether patients have been harmed, or are at risk of harm, as well as helping to avoid future harm to patient. Patients may be harmed not only by clinical treatment, but also as a result of the need to be on a waiting list for clinical treatment, as this may result in deterioration of their physical or mental condition. Royal Cornwall Hospitals standard operating procedure (SOP) identifies a standardised approach to harm reviews for all specialities at the Trust that support the Trusts' governance and assurance processes and maintains practice in line with national expectations.
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- Patient harmed
- Standards
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Content ArticleJulie Avery and Brian Edwards, Chartered Institute of Ergonomics and Human Factors, presented at the recent Human Error Forum. They share their presentation slides on human performance and organisational learning and how to integrate human performance into existing systems.
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- Human error
- Human factors
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Content ArticleThis scoping paper explores the question ‘what would it take to build a culture of learning at scale?’. It focuses on systems-wide learning that can help to inform systems change efforts in complex contexts. To answer this question, literature was reviewed from across diverse disciplines and the realms of education, innovation systems, systems thinking and knowledge management. This inquiry was also supported by in-depth interviews with numerous specialists from the for-purpose sector and the examination of several case studies of learning across systems. The goal was to derive common patterns to inform a ‘learning for systems change’ framework. In this paper, a ‘learning networks’ approach is proposed, one that draws upon individual, group and systems-wide learning to build capacity and resilience for systems change in uncertain environments. This fills a gap in the literature where the focus is largely on learning within organisations. Instead, the focus here is on what is required to support learning to occur across scales and boundaries - from the individual to system-wide. A simple meta-framework for developing learning networks is proposed that includes high level guidance on the enabling conditions - the mindsets, relationships, processes and structures - that would enable learning networks to flourish.
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- Safety culture
- Organisational learning
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Content Article
Thought piece on the Ockenden Report by Susan Stanford
Patient Safety Learning posted an article in Maternity
People with an interest in patient safety read the interim Ockenden report with despair. It was immediately and starkly apparent that it repeated many of the common themes which have emerged in other patient safety investigations. Many of the recommendations in the Ockenden report were already covered by national guidance, Susan Stanford asks why the guidance wasn’t followed and whether it might not be being followed elsewhere.- Posted
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- Investigation
- Recommendations
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Content ArticlePatient safety incidents (PSIs) are common and can lead to fatal outcomes. Effective investigation of PSIs is essential to optimise learning and take action to prevent further incidents occurring. The Yorkshire Contributory Factors Framework is a tool which has an evidence base for optimising learning and addressing causes of patient safety incidents by helping clinicians, risk managers and patient safety officers identify contributory factors of PSIs. Incidents that occur in a hospital setting have been well studied and all contributory factors have been mapped. Based on this research, a team of practicing clinicians with human factors experts has adapted the evidence to a pragmatic 2 page framework. The document suggests questions that you might want to ask of those involved in the incident. The underlying aim of this tool is not to ignore individual accountability for unsafe care, but to try to develop a more sophisticated understanding of the factors that cause incidents.
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- Investigation
- Patient safety incident
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Content ArticleThis report by The Right Reverend James Jones KBE aims to provide an insight into what the bereaved Hillsborough families experienced in the years following the Hillsborough disaster in April 1989. It seeks to place their insight on the official public record in the hope that their suffering and experience will bring about changes to the way in which public institutions treat people who have been bereaved. It records family members' experiences of interacting with the authorities after the disaster and around the different inquests, and highlights 25 points of learning for public institutions.
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- Duty of Candour
- Transparency
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Content ArticleThis template has been published to guide local PSIRP early adopter organisations in prioritising investigation quality over quantity. NHS providers should follow this template when developing their local patient safety incident response plan.
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- Patient safety incident
- Investigation
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Content ArticleThe Serious Incident framework describes the process and procedures to help ensure serious incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again. This framework explains the responsibilities involved when dealing with serious incidents and includes actions staff are required to take, and the tools available. It is designed to inform staff providing and commissioning NHS funded services in England who may be involved in identifying, investigating or managing a serious incident. It is relevant to all NHS-funded care in the primary, community, secondary and tertiary sectors, including private sector organisations providing NHS-funded services. At some point in 2022, the Serious Incident framework will be replaced by the Patient Safety Incident Response Framework
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- Patient safety incident
- Organisational learning
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Content ArticleThe national Perinatal Mortality Review Tool (PMRT) was developed with clinicians and bereaved parents in 2017 and launched in England, Wales and Scotland in early 2018; it was subsequently adopted in Northern Ireland in autumn 2019. The aim of the PMRT programme is to support standardised perinatal mortality reviews across NHS maternity and neonatal units. Unlike other reviews or investigation processes, the PMRT makes it possible to review every baby death after 22 weeks’ gestation, and not just a subset of deaths. This report presents data from the 3,981 reviews which were completed between March 2020 and February 2021.
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- Patient death
- Baby
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Content ArticleThis guide provides guidance for hospital clinical staff and managers in the secondary care of COVID-19 patients, based on the experience of hospital trusts that performed well during the early phase of the pandemic. It summarises the challenges faced by, and responses of, several high performing trusts visited as part of the GIRFT cross-specialty COVID-19 deep dives, as well as identifying successful innovations they implemented.
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- Hospital ward
- Pandemic
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Content Article
The Journal of Patient Safety
Patient-Safety-Learning posted an article in Research
Full articles require a subscription to the journal but the abstracts can be viewed free of charge.- Posted
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- Patient safety strategy
- Organisational learning
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