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Showing results for tags 'Organisational learning'.
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Content ArticleOn 2 September 2006, all 14 crew of a UK Royal Air Force (RAF) ‘spy plane’ Nimrod XV230 were lost following a catastrophic mid-air fire. The aircraft was on a routine mission when a leak of aviation fuel, shortly after air-to-air refuelling, came into contact with a source of ignition. The fire was not accessible, not able to be remotely suppressed, and the incident was not survivable. ‘The Nimrod Review’, led by The Hon. Mr Justice Haddon-Cave, is a model investigation, and should be required reading for executives and leaders in all industries. The Review takes the aircraft fire as its starting point, but casts its net far and wide through the organisation, as well as considering relevant events in other industries. This Nimrod XV230 tragedy is so rich in lessons, Martin Anderson, Chartered Human Factors Professional, shares on his website a series of articles about the Nimrod XV230.
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- Aviation
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Content ArticleIn most cases pregnancy and birth are a positive and safe experience for women and their families. This is the outcome that everyone working in maternity services wants every time, for every woman. But when things go wrong, we need to understand what happened, and whether the outcome could have been different. The death or injury of a new baby or mother is devastating and something that everyone working in the health and care system has a responsibility to do all they can to prevent. Following the publication of ‘Getting safer faster’ the Care Quality Commission (CQC) launched a programme of risk-based, focused maternity safety inspections involving a more focused in-depth assessment of relational elements such as teamworking and culture, staff and patient experience. Building on our previous calls for action, the CQC also sought to further explore the barriers that prevent some services from providing consistently good, safe care and to better understand the disparities in outcomes that exist for women and babies from Black and minority ethnic groups. This report presents the key themes from nine of those inspections alongside insight gathered from direct engagement with organisations representing women using maternity services and their families, including Five X More and local Maternity Voices Partnerships.
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- Maternity
- Patient harmed
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Content Article
'Whistleblowing': a definition for reflection in Speak Up Month
Steve Turner posted an article in Whistle blowing
It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."- Posted
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- Accountability
- Bullying
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Content ArticleAlthough many initiatives have been implemented and great strides have been achieved in improving patient safety and reducing preventable medical errors, progress towards achieving "zero" avoidable harm continues to be slow. This video presentation will address common medical errors, their recognition, potential for harm and the psychological and financial costs. The concepts of human factors, system design and the high reliability organisation will be reviewed. New approaches in reducing harm and restoring trust will be described along with the opportunity for physician leadership.
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- Human factors
- Human error
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Content ArticleThe COVID-19 pandemic has profoundly impacted the country’s health systems and diminished its capability to provide safe and effective healthcare. This article from Sharda Narwal and Susmit Jain attempts to review patients safety issues during COVID-19 pandemic in India, and derive lessons from national and international experiences to inform policy actions for building a ‘resilient health system’
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Content ArticleIn his latest blog, Ehi Iden, hub topic lead for Occupational Health and Safety, OSHAfrica, discusses the importance of documenting and learning from patient safety incidences. Using a fictional story to draw parallels from, Ehi highlights how accountability, leadership and reporting incidences will help us keep staff and patients safe.
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- Accountability
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Content ArticleThis first webinar of Global Patient Safety Webinar Series 2021 introducing the “WHO Patient Safety Incident Reporting and Learning Systems: Technical report and guidance” which was released on 17 September 2020 on World Patient Safety Day. The webinar presented an overview of the technical guidance, and the country experiences on implementing and managing the patient safety incident reporting and learning systems. A recording of the webinar is available below.
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- Patient safety incident
- Reporting
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Content ArticleThis is the coroners report into the death of Brandon-Robert, who was born on 29 May 2020, and died of E. coli sepsis a week later.
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- Coroner reports
- Patient death
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Content ArticleVisual representation from Steven Shorrock on a quick way to evaluate where you can improve the flows of reporting within your organisation. The red highlights stronger influences.
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- Human factors
- Reporting
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Content ArticleThe precautionary principle is important in high risk, high harm, safety critical work. Risks to workers, customers, or service users are substantial, and so the precautionary principle in which precautions are taken until safety is proven, often apply. However, in healthcare it’s different. Healthcare takes the approach that the status quo applies until something is proven dangerous and harmful. The burden of proof is often high and often falls to the workforce to “prove.” Alison Leary, Professor of healthcare and workforce modelling at London South Bank University, in this BMJ article discusses the reasons healthcare fails to heed the precautionary principle and why potentially the cost of doing so is high and ultimately catastrophic.
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- Organisational culture
- Organisational learning
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Content ArticleMore than 30 years have passed since the near-fatal medication error but Michael Villeneuve, CEO Canadian Nursing Association, recalls the moment with absolute clarity.
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- Medication
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Content ArticleThe Coroners and Justice Act allows coroners in England or Wales to issue reports after inquest, if they believe that action should be taken to prevent a future death. Coroners are under a statutory duty to issue a Prevention of Future Death (PFD) report to persons or organisations that they believe have the power to act. Cumulatively, these reports may contain useful intelligence for patient safety.
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- Coroner reports
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Content ArticleQuality improvement and patient safety have been important topics on the agenda in the Danish health care system for >20 years. Over the years, Denmark has developed an array of national quality and patient safety initiatives. This paper aims to describe how quality improvement and patient safety initiatives have been organised in the Danish health care system and highlight how accountability has been achieved.
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- Europe
- Organisational Performance
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Content ArticleThere is widespread consensus that learning is crucial for the performance of health systems and the achievement of broader health goals. However, this consensus is not matched by shared knowledge and understanding of how health systems learn, or of how to improve health systems learning across different contexts. The report is aimed at an audience of diverse stakeholders invested in strengthening health systems, and aims to achieve two things. First, to move towards a shared language and frameworks to discuss the problems and solutions of learning, as they apply to health systems. Second, the report seeks to advance action on learning – by providing stakeholders with clarity on steps that they can undertake to advance learning for health systems. This report is intended to be a starting point for gaining a shared understanding of learning health systems as an actionable agenda. The hope is that it will spur useful conversations and fuel the movement for better informed, more analytical and more self-reliant health systems – especially in the context of low- and middle-income countries.
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- System safety
- Quality improvement
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Content ArticleA stronger safety climate in nursing homes may reduce avoidable adverse events. Yet efforts to strengthen safety climate may fail if nursing homes are not ready to change. To inform improvement efforts, Quach et al. examined the link between organisational readiness to change and safety climate. They found that organisational readiness to change predicted safety climate. Safety climate initiatives that address readiness to change among frontline staff and managers may be more likely to succeed and eventually increase resident safety.
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- Care home
- Organisational development
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Content ArticleWorking together and maximising the benefits of intelligent technology can have a truly transformative impact on clinical negligence claims, writes Molly Kent, a patient safety specialist at Radar Healthcare, in this HSJ article. Claims essentially arise out of dissatisfaction, usually with a process, service or poor patient journey. Each claim represents an individual’s story – no two cases will be identical, just as no two patients are identical. Molly argues, however, that it’s when we bring the information from claims together that we can truly learn. Rather than looking at each case in its own silo, we should be building the big picture, and considering things like systems of internal control, human factors, communications, audit and education.
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- Negligence claim
- Legal issue
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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 introduce the PMRT to support standardised perinatal mortality reviews across NHS maternity and neonatal units Unlike other review 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 3,693 reviews which were completed between March 2019 and February 2020.
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- Baby
- Patient death
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Content ArticleIn this video, Tim McDonald, Chief Patient Safety and Risk Officer at RLDatix, Paul Bowie, Programme Director (Safety & Improvement) at NHS Education for Scotland, and Helen Hughes, Chief Executive of Patient Safety Learning, talk about the relationship between human factors, high reliability in healthcare and patient safety.
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- Human factors
- Ergonomics
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Content ArticleIn this 30 minute film, Adrian Plunkett introduces the concept and history of learning from from excellence. Content also includes: Safety-II Positivity language Negativity bias.
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- Safety II
- Organisational culture
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Content ArticleThis blog looks at how positive reporting of good practice and success can help support health systems and organisations in their journey to become highly reliable and improve patient safety. This is part of a joint series of blogs and video conversations exploring how we can improve patient safety through the application of principles of high reliability in healthcare, made collaboratively by Patient Safety Learning and RLDatix.
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- Organisational culture
- Patient safety incident
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Content ArticleA new best practice guide helping trusts learn more from NHS negligence claims has been issued in the drive for better patient safety. With the cost of harm for clinical negligence claims from incidents in 2019/20 expected to cost the NHS £8.3 billion, the Getting It Right First Time (GIRFT) programme and NHS Resolution have worked together to produce 'Learning from Litigation Claims', offering trust clinicians, managers and legal teams a practical and structured approach to claims learning, and sharing examples of best practice from across England. The aim is to maximise what can be learned from litigation, for the benefit of patients and to curb escalating costs.
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- Negligence claim
- Complaint
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Content ArticleImproving the design of technology relies in part, on the reporting of performance failures in existing devices. Healthcare has low levels of formal reporting of performance and failure of medical equipment. This paper from Tase et al. examines methods of reporting in the car industry and healthcare and aims to understand differences and identify opportunities for improvement within healthcare.
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- Medical device
- Organisational learning
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Content ArticleSue Hignett and Paul Bowie propose taking a much-needed professional approach to patient safety through an accredited learning pathway to integrate safety into clinical systems and develop healthcare safety specialists and experts
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- Patient harmed
- Organisational learning
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Content ArticleSafety governance refers to the approaches taken to minimise the risk for patient harm across an entity or system. It typically comprises steering and rule-making functions such as policies, regulations and standards. To date, governance has focused on the clinical level and the hospital setting, with limited oversight and control over safety in other parts of the health system. All 25 countries that responded to a 2019 OECD Survey of Patient Safety Governance have enacted legislation that aims to promote patient safety. These practices include external accreditation and inspections of safety processes and outcomes. Safety governance models are also moving away from punishment and shaming towards increased trust and openness. Learning from success as well as failures represents a paradigm shift in safety governance, an approach that has been increasingly adopted in OECD countries.
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- System safety
- Implementation
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Content ArticleJoe Rafferty, Chief Executive of Mersey Care NHS Foundation Trust, explains Mersey Care's strategy to pursue 'perfect care' and why it requires a cultural shift that is dependent on a paradigm shift in mind-set, behaviour and practice.
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- Psychological safety
- Staff safety
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