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Showing results for tags 'Safety II'.
Found 60 results
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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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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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Screening incidents: thinking differently
PatientSafetyLearning Team posted an article in Improving patient safety
In this blog, Suzette Woodward, an international expert on patient safety, advises Public Health England on its review of the screening incident guidance, setting out her thoughts on how learning from safety incidents could be strengthened. -
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Gavin Portier is Head of Nursing Quality at Barnsley Hospital NHS Foundation Trust. In this interview, Gavin explains how his approach to auditing has moved beyond measuring negative outcomes, instead focusing on standards of care. -
Content ArticleThe purpose of this guide from NHS Education for Scotland is to help people working in the health and social care ecosystem capture valuable practice and improvements made during their response to COVID-19. The aim is to contribute to organisational change at a policy, strategic and operational level. If left too late, there is a real danger that positive change is not documented and will be lost as the health system emerges from the pandemic.
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Content ArticleA sub-group of rare but serious patient safety incidents, known as ‘never events,’ is judged to be ‘avoidable.’ There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of ‘preventable harm’ with zero tolerance ‘never events,’ especially around the lack of evidence for such harm ever being totally preventable. Bowie et al. consider whether the ideal of reducing preventable harm to ‘never’ is better for patient safety than, for example, the goal of managing risk materialising into harm to ‘as low as reasonably practicable,’ which is well-established in other complex socio-technical systems and is demonstrably achievable. They reflect on the ‘never event’ concept in the primary care context specifically, although the issues and the polarised opinion highlighted are widely applicable. Recent developments to validate primary care ‘never event’ lists are summarised and alternative safety management strategies considered, e.g. Safety-I and Safety-II.
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Learning from excellence in healthcare
Patient Safety Learning posted an article in Implementation of improvements
Learning from everyday work means learning from all activities regardless of the outcome. But when things go well, this is typically just gratefully accepted, without further investigation. ‘Learning from Excellence’ is changing this, as Adrian Plunkett and Emma Plunkett describe in this article. -
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Ben Watson is a Strategy Implementation and Quality Improvement (SIQI) Manager in the Scottish Ambulance Service. He is currently responsible for supporting operational services in the West of Scotland, to see how they can improve patient care, existing processes and develop new ways of working that benefit both staff and patients. In this interview, Ben explains why they’ve started collecting positive feedback through a peer-to-peer system called GREATix. -
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Intensive Care bed space orientation
Claire Cox posted an article in Other health and care software
This interactive orientation of an Intensive Care Unit (ICU) bed space, created by the London Transformation and Learning Collaborative, is ideal for healthcare professionals new to the ICU environment. It allows you to explore the risks and demonstrated the safety check required to keep patients safe in the ICU. This application is best used with a smart phone, but can be used on a computer. -
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GREATix: Reporting the positive
PatientSafetyLearning Team posted an article in Safety culture programmes
The Scottish Ambulance Service has recently launched a positive reporting scheme called GREATix. GREATix is a peer-to-peer tool for recognising and learning from positive feedback in the workplace. Feedback will be used to pass on words of gratitude and identify improvement strategies. -
Content ArticleThe ‘Learning from Excellence’ (LfE) programme aims to provide a means to identify, appreciate, study and learn from episodes of excellence in frontline healthcare. The aim of this study, published in the British Journal of Healthcare Management, was to explore the impact of LfE on organisational performance in NHS trusts in the United Kingdom (UK), how this impact is achieved and which contextual factors facilitate or hinder impact.
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Some personal reflections on how the varieties of human work as summarised by Steven Shorrock apply to healthcare and personal experiences within the NHS. I offer some considerations of how this type of thinking should inform the activity of those working in patient safety oversight roles where they are not in close and regular contact with staff delivering frontline services. -
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Rethinking Patient Safety: Maternity safety (4 October 2020)
Patient Safety Learning posted an article in Maternity
Suzette Woodward reflects on the recent reports and research into maternal safety and why we need to shift to a Safety II approach. -
Content ArticleWhen things go wrong, we seem to display a reliable tendency to do one thing: blame those at the ‘sharp end’. No matter how complex the system, how uncertain the situation, or how inadequate the conditions, our attention post-accident seems to turn to those proximal to the consequence, whom we judge to have failed to control the hazard in question. The notion of ‘just culture’ has developed over the past decade or so in response to this and is highly valued by front line staff. Just culture is, however, borne of the Safety-I mindset. Since the advent of ‘just culture’, the Safety-II perspective has emerged. Safety-II defines safety not as avoiding that things go wrong but as ensuring that things go right. Safety-II views the human not as a hazard, but as a resource necessary for system flexibility and resilience. In light of this, it has been proposed that the idea of just culture should be abandoned. If we take a Safety-II view, ‘just culture’ might indeed seem unnecessary. Steve Shorrock explores this further in his latest blog.
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Content ArticleNeil Spenceley is a paediatric intensivist and is the National Lead for Paediatric Patient Safety. This talk is packed with nuggets that will change the way you view the world in which you practice. Neil explains Safety 1 and Safety 2 thinking. The talk is wide-ranging and covers poor behaviours in healthcare both at a personal level and at an institutional level. This talk was recorded live at Don't Forget the Bubbles 2019 in London, England.
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EventuntilThe Flight Safety Foundation goal with this Seminar is to promote further globally the practical implementation of the concepts of system safety thinking, resilience and Safety II. There will be two sessions, one for each day, that will consist of briefings and a Q&A panel afterwards. The following themes are suggested for briefings and discussions for the Seminar 1.The limits of only learning from unwanted events. 2. Individuals’ natural versus organisations’ consciously pursued resilience. 3. How the ancient evolutionary individual instincts for psychological safety affect individual and team learning and how these can be positively managed? 4. The slow- and fast-moving sands of operations and environment change over time and their significance for safety. 5. How to pay as much attention to why work usually goes well as to why it occasionally goes wrong? 6. Understanding performance adjustments of individuals to get the job done. 7. The blessings and perils of performance variability. 8. Learning from data versus learning from observing. 9. Learning from differences in operations versus learning from monitoring for excrescences. 10. Can risk- and resilience-based concepts work together? 11. Does just culture matter for learning from success? 12. How to document explicitly, maintain current and use the information about success factors and safety barriers and shall this be a part of organisational SMS? Further information
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Content Article
Annual SHOT report 2019
Patient Safety Learning posted an article in Other
SHOT (Serious Hazards of Transfusion) is the UK's independent professionally led haemovigilance scheme. This year’s Annual SHOT Report looks back at trends and data for the last calendar year, but also highlights several very important messages for us in the present extraordinary times. The data in the report come from across the UK and include material from all areas of healthcare where transfusion is practised. -
Content ArticleThis info-graphic by the Faculty of Pain Medicine is a safety checklist for Interventional Pain Procedures under local anaesthesia or sedation. This has been adapted from the World Health Organization surgical checklist.
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Content Article
Podcast: Incident reporting
PatientSafetyLearning Team posted an article in Good practice
Richard Smith is a trained paramedic who now works as Head of Quality and Safety at Addenbrooks Hospital. In this interview with East England Ambulance Service General Broadcast, Richard talks about his recent paper on incident reporting in the ambulance service. He asks if we have a blame and fear-free culture when concerns are raised, the value of feedback and highlights the importance of reporting the positive incidents too. -
Content ArticleThe Lilypond is a new conceptual model to describe patient safety performance. It radically diverges from established patient safety models to develop the reality of complexity within the healthcare systems as well as incorporating Safety II principles. There are two viewpoints of the Lilypond that provide insight into patient safety performance. From above, we are able to observe the organisational outcomes. This supersedes the widely used Safety Triangle and provides a more accurate conceptual model for understanding what outcomes are generated within healthcare. From a cross-sectional view, we are able to gain insights into how these outcomes come to manifest. This includes recognition of the complexity of our workplace, the impact of micro-interactions, effective leadership behaviours as well as patterns of behaviour that all provide learning. This replaces the simple, linear approach of The Swiss Cheese Model when analysing outcome causation. By applying the principles of Safety II and replacing outdated models for understanding patient safety performance, a more accurate, beneficial and respectful understanding of safety outcomes is possible.
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What’s the plan?
Eve Mitchell posted an article in Exit strategies
In her latest blog for the hub, topic lead Eve Mitchell discusses what we need to do as we plan for recovery post-covid. Despite an apparent increase in interest in joining the nursing profession since the start of the pandemic, the reported 40,000 gap in nursing numbers is not going to be closed overnight and we therefore need to plan for different, re-think roles and responsibilities, and capture and capitalise on the innovations that have flourished in some areas. As we begin to reorient, revise our goals and focus on moving beyond rather than on just ‘getting by’, it is important that we look at all settings of care so we can learn from excellence, build on the best and support a faster response in the future if required. -
Content Article
Dirty Dozen and COVID-19 (webinar, May 2020)
Claire Cox posted an article in Coronavirus (COVID-19)
There are fears around maintaining personal safety whilst ensuring patient safety. Staff need to protect both themselves and their families at home. Equally, it is essential that staff feel supported in identifying risks and the potential for errors with a robust mechanism in place to reduce, eliminate or mitigate such risks. The Human Factors 'Dirty Dozen' is a concept developed by Gordon DuPont. He described elements that can act as precursors to accidents or incidents, or influence people to make mistakes. This webinar, from the Clinical Excellence Commission, looks at ways you can identify risks or 'hot spots' in your area of work and then discuss with your team at handover and huddles and plan strategies to reduce, eliminate or mitigate the risks -
Content ArticleThe CARe QI handbook is based on research in a range of healthcare organisations and settings, including acute care, primary care, care homes, oral health and community settings. It was designed to provide practical tools to apply ideas from resilient healthcare to quality improvement.
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Content ArticleOn Thursday 28 April, Q’s Organisational Resilience & Safety-II group organised a special zoom session to explore how practice is changing in the light of our COVID-19 response. Follow a virtual meeting discussing Safety-II in action during COVID-19, hosts Simon Gill, Suzette Woodward and Paul Stretton share a summary of insights from the session.
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Content ArticleRecently, there has been a lot of interest in some ideas proposed by Prof. Erik Hollnagel and labeled as “Safety-II” and argued to be the basis for achieving system resilience. He contrasts Safety-II to what he describes as Safety-I, which he claims to be what engineers do now to prevent accidents. What he describes as Safety-I, however, has very little or no resemblance to what is done today or to what has been done in safety engineering for at least 70 years. In this paper, Prof. Nancy Leveson, Aeronautics and Astronautics Dept., MIT, describes the history of safety engineering, provides a description of safety engineering as actually practiced in different industries, shows the flaws and inaccuracies in Prof. Hollnagel’s arguments and the flaws in the Safety-II concept, and suggests that a systems approach (Safety-III) is a way forward for the future.
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