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Found 207 results
  1. Content Article
    This paper explores work from: Plsek and Greenhalgh Charles Vincent and Rene Amalberti Erik Hollnagel
  2. Content Article
    Through SHIFT to Safety, the CPSI will help: Patients and their families shift to advocate for their healthcare safety. Healthcare providers shift to prioritise safety when caring for patients. Leaders in healthcare organisations shift to create a positive patient safety culture. SHIFT to Safety promotes a positive, safe healthcare experience for patients, providers, and leaders in healthcare organisations. The tools and resources empower everyone to understand how to make safety a priority while navigating the healthcare system. Includes a short video explaining SHIFT to Safety.
  3. Content Article
    Anniversaries are special. They acknowledge events from personal to the historic. I just celebrated an anniversary that met both those criteria: 25 years of marriage. I did so in a place marking the centennial of its designation as a national park – a true American wonder – the Grand Canyon. It goes without saying that the place is gobsmacking: it literally takes your breath away. It is no easy feat to navigate the options for what can be done while you are there – the food, the views, the trails, the crowds, the mules! To make the trip really monumental however, visitors and staff need to keep safety in mind. Just as clinicians, patients and families do while they are in the hospital. They need to get informed, prioritise activities and trust judgment to manage risk. Distributing good, freely available information The Grand Canyon Visitor’s centres and trail heads provide a cornucopia of maps, pamphlets and booklets highlighting options for activities. Making information and data available is key to keeping a visitor to the Canyon free from harm. Similar to trail maps noting loose rocks, unmaintained walkways and mudslide potential, the US Pennsylvania Patient Safety Authority (PSA) models the important mission of transparency by sharing what they learn about threats to safety. The organisation has been collecting and analysing adverse event and other data for 15 years. The Authority disseminates it not only to generate action within their state, but throughout healthcare. Their new open access journal, Patient Safety, continues down a trail established by the PSA newsletter. This work will help all of us progress by providing insights to manage both unseen and known obstacles to safety. Prioritising action Grand Canyon National Park offers a wide array of choices for visitors. If you only have a day or two in the region, prioritising what hike to take and when to go takes some planning. Just as in safety where the options, tools and improvement goals can become overwhelming. It is crucial to have a method to sort things out. In both instances there is so much to do! Recently the US Veterans Administration (VA) health system published a paper on the process they use to prioritise efforts in their system. They summarised an approach that rests on a foundation of learning practices that could be helpful for all of us to consider in moving forward. Trusting your gut My husband in his college days hiked down the Canyon to the Colorado river and back up three separate times. Those treks gave him experience that enabled him to know when “worry” was worth listening to as we ventured down a rugged, steep, trail during our visit. We went down and came back up into the Canyon safely. A recent study from the US, published in JAMIA Open, looked at the accuracy of nursing judgement as a barometer for patient deterioration. The “Worry Factor” proved to be a darn good signal – over 75% of deterioration situations were correctly identified by nurses ahead of time. Then there are the others Do you ever wonder “what the ???” when you see people doing something in a park – there are signs everywhere NOT to do ... but they do it anyway? Scampering up rocks behind the safety railing, feeding squirrels, trudging down a rocky trail in flip flops! Safety messages are posted all over the park in an effort to keep Grand Canyon visitors safe. Of course, humans being human, don’t always follow the advice due to arrogance, language issues or a myriad of factors – the distraction caused by the beauty and awe of the place being one of them. Same goes for healthcare. Unintended consequences of process and environment complexity can derail efforts to keep patients safe. Bureaucracy can undermine efforts to keep large systems resourced to provide high quality care delivery, as we heard in a recent examination of the US Indian Health Service. Despite efforts to monitor opioid prescribing practices of physicians, the behaviours are notoriously persistent. Transparency and accountability for failure, while heralded as core attributes of safe care, are not always available to patients. Patient safety and life are both grand adventures that we can navigate through the effective use of information, prioritisation and sound judgment. I hope you all have as good a partner in your journeys as I have had in mine.
  4. Content Article
    Key take home messages Placing our faith in data management to improve patient experience at the frontline is dangerous. The fixation on right solutions, the desire to roll-out changes quickly and an assumption that impact measurement as depicted on a graph, do not help and potentially even distract emphasis away from the human interactions that patients and their relatives need. The positive ways that staff responded to an approach that allows them to put concepts of data to one side, and that gives them permission to relate on more human levels, suggests that they too need these interactions. Large datasets have their place in large organisations but perhaps are best kept away from frontline care.
  5. Content Article
    The ThinkSAFE Logbook has four sections: Information about you. How you can help enhance your safety in hospital. Information and notes about your care. Other useful information for patients and families. The Logbook also includes a number of useful tools, tips and prompts to help you and the healthcare staff caring for you to share information. This will help you to be involved and informed about your care and treatment. The pages are ordered so that when they are printed double-sided they create an A5 booklet. Once printed, the pages can be folded and then either stapled down the fold to create a soft cover booklet, or hole-punched to fit inside an A5 ring-binder folder.
  6. Content Article
    Reminder: Advise patients not to: smoke; use naked flames (or be near people who are smoking or using naked flames); or go near anything that may cause a fire while emollients are in contact with their medical dressings or clothing. Change patient clothing and bedding regularly—preferably daily—because emollients soak into fabric and can become a fire hazard. Incidents should be reported.
  7. Content Article
    Key points: Building an organisation-wide approach to improvement is a journey that can take several years. It requires corporate investment in infrastructure, staff capability and culture over the long-term. An essential early step is securing the support and commitment of the board for a long-term programme, including their willingness to finance the skills and infrastructure development needed to implement it. The report includes case studies of three English NHS trusts with an outstanding CQC rating that have implemented an organisational approach to improvement.
  8. Content Article
    This page includes; Who should be a patient safety specialist Developing the patient safety specialist role Responsibilities Training Networks.
  9. Content Article
    Key findings: Successive governments have pursued policies to improve the quality of care in the NHS, but the many and varied initiatives failed through a lack of consistency and the distraction of other reforms. Efforts to improve quality of care have been hampered by competing beliefs about how improvements are best achieved. More than ever, the NHS must focus on delivering better value to the public. This means tackling unwarranted variations in clinical care, reducing waste, becoming more patient- and carer-focused, and ensuring that quality and safety are at the top of the health policy agenda. This is best done by supporting clinical leaders through education and training in quality improvement methods, and developing organisational cultures where leaders and staff focus on better value as a primary goal. Clarity about the role of inspection in a quality improvement system is vital. Done well, inspection has a part to pay in quality assurance – but this should not be confused with quality improvement.
  10. Content Article
    The plan focuses on building an NHS fit for the future by: enabling everyone to get the best start in life helping communities to live well helping people to age well. The plan has been developed in partnership with frontline health and care staff, patients and their families. It will improve outcomes for major diseases, including cancer, heart disease, stroke, respiratory disease and dementia.
  11. Content Article
    The topics on this website cover four priority areas of patient safety: medication safety surgical care safety infection prevention and control home care safety.
  12. Content Article
    The guide is for anyone involved with patient engagement, including: patients and families interested in how to partner in their own care to ensure safety patient partners interested in how to help improve patient safety providers interested in creating collaborative care relationships with patients and families managers and leaders responsible for patient engagement, patient safety, and/or quality improvement anyone else interested in partnering with patients to develop care programs and systems. While the guide focuses primarily on patient safety, many engagement practices apply to other areas, including quality, research, and education. The guide is designed to support patient engagement in any healthcare sector.
  13. Content Article
    Learning objectives At the end of this activity, you will be able to: List three principles of reliable systems. Explain how the Central Florida Zoo uses these three principles in protecting staff from venomous snakes. Discuss how the zoo’s safety system can be applied to health care.
  14. Content Article
    This paper presents eight steps that are recommended for leaders to follow to achieve patient safety and high reliability in their organisations. Each step and its component parts are described in detail in the sections that follow, and resources for more information are provided where available. Address strategic priorities, culture and infrastructure. Engage key stakeholders. Communicate and build awareness. Establish, oversee and communicate system-level aims. Track/measure performance over time, strengthen analysis. Support staff and patients/families impacted by medical errors. Align system-wide activities and incentives. Redesign systems and improve reliability.
  15. Content Article
    Key findings: Though PPI is increasingly common in healthcare research, there is limited agreement about how, when, and why it should best be done. Patients and the public get involved in research for a variety of reasons but often because they want to help others and contribute to a better healthcare system. To enable involvement, PPI needs to be funded adequately, opportunities need to be clearly communicated, and support needs to be available for researchers and PPI contributors. More PPI on its own doesn’t necessarily mean better research, and doing PPI just for the sake of it can discourage researchers and disenfranchise people who get involved. PPI should be relevant and meaningful for the research and the people involved. PPI has the potential to improve research and empower contributors, but evidence about how that actually happens, to what extent, and to what effect, is limited. To monitor and evaluate PPI, researchers will need to agree on what study designs are appropriate, be clear about what PPI activities are meant to achieve, and focus evaluations on the process of PPI and/or its contributions to research.
  16. Content Article
    Findings Participants’ perceptions regarding their engagement as a patient safety strategy were expressed through three overarching themes: the word 'patient' obscures the message safety is a shared responsibility involvement in safety is a right. Themes were further defined by eight subthemes. Conclusions Using direct messaging, such as 'your safety' as opposed to 'patient safety' and teaching patients specific behaviours to maintain their safety appeared to facilitate patient engagement and increase awareness of safety issues. Patients may be willing to accept some responsibility for ensuring their safety by engaging in behaviours that are intuitive or that they are clearly instructed to do. However, they described their involvement in their safety as a right, not an obligation. Interpretation Clear, inviting communication appears to have the greatest potential to enhance patients’ engagement in their safety. Nurses’ ongoing assessment of patients’ ability to engage is critical insofar as it provides the opportunity to encourage engagement without placing undue burden on them. By employing communication techniques that consider patients’ perspectives, nurses can support patient engagement.