Jump to content

Search the hub

Showing results for tags 'Safety II'.


More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


Forums

  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous

Categories

  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
    • Questions around Government governance
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient Safety Partners
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training & education
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous

News

  • News

Categories

  • Files

Calendars

  • Community Calendar

Find results in...

Find results that contain...


Date Created

  • Start
    End

Last updated

  • Start
    End

Filter by number of...

Joined

  • Start

    End


Group


First name


Last name


Country


Join a private group (if appropriate)


About me


Organisation


Role

Found 59 results
  1. Content Article
    In this blog, nurse Carol Menashy describes her experience making an error in theatre fifteen years ago, and the personal blame she faced in the way the incident was dealt with at the time. She talks about how a SEIPS (Systems Engineering Initiative for Patient Safety) framework can transform how adverse incidents are dealt with, allowing healthcare teams to learn together and use incidents to help make positive changes towards patient safety. She describes the progress that has been made towards organisational accountability and systems thinking over the past fifteen years, and talks about the importance of staff support to allow for healing from adverse events.
  2. Content Article
    Safety II moves away from simply looking at what went wrong, and aims to understand the realities of everyday work in a constructive and positive way. It focuses on the system as a whole, rather than the end result of the work done. In this blog, Professor Suzette Woodward, Professional and Clinical Advisor in Patient Safety, looks at the role of the Safety II approach in making maternity services safer. She outlines the importance of asking and listening to staff about how to reduce complexity and reform areas of the system that are prone to error.
  3. Content Article
    Are you applying Safety-II principles to improve safety in maternity, A&E, ICU or anaesthetics? If so, Dr Ruth Baxter would love to interview you!
  4. Content Article
    Historical and current methodologies in patient safety are based on a deficit-based model, defining safety as the absence of harm. This model is aligned with the human innate negativity bias and the general philosophy of health care: to diagnose and cure illness and to relieve suffering. While this approach has underpinned measurable progress in healthcare outcomes, a common narrative in the healthcare literature indicates that this progress is stalling or slowing. It is important to learn from and improve poor outcomes, but the deficit-based approach has some theoretical limitations.
  5. Content Article
    This paper, summarised in the Journal of Hospital Administration, concludes: "Embedding Restorative Just Culture and Safety II concepts into the incident review process is associated with improved measures of culture and review outputs. The integration of Safety II concepts and support of cultural shifts will require further work and committed leadership at all levels."
  6. Content Article
    In this blog, Ted Baker, Former Chief Inspector of Hospitals at the Care Quality Commission, suggests that a false view that health services are intrinsically safe leads to defensive responses to safety concerns and perpetuates a culture of blame. He argues that the mismatch between safety as described and the reality of safety in practice prevents healthcare professionals being able to speak up about safety concerns. By taking an alternative approach that accepts the risk inherent in healthcare and the fallibility of individuals, he believes we can build organisations and systems that really learn from safety events. In order to do this, we need staff to feel able and supported to speak up, something that can be achieved through widespread understanding of safety society and building a supportive culture. Ted argues that this open culture is still lacking within many services.
  7. Event
    until
    The 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
  8. Content Article
    The ‘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.
  9. Content Article
    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.
  10. Content Article
    When 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.
  11. Content Article
    Suzette Woodward reflects on the recent reports and research into maternal safety and why we need to shift to a Safety II approach.
  12. Content Article
    A 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.
  13. Content Article
    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.
  14. Content Article
    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. 
  15. Content Article
    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.
  16. Content Article
    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.
  17. Content Article
    Neil 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.
  18. Content Article
    The 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.
  19. Content Article
    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.
  20. Content Article
    In this blog, Steven Shorrock discusses Learning Teams, small group conversations and action, and makes a case for learning in the following ways: talk about everyday work start with what’s strong, not what’s wrong find ways to cross departmental boundaries and get multiple perspectives understand first what can be done by teams.
  21. Content Article
    ‘Safety differently’ is about relying on people’s expertise, insights and the dignity of 'work as actually done' to improve safety and efficiency. It is about halting or pushing back on the ever-expanding bureaucratisation and compliance of work. The cost of compliance and bureaucracy can be mind-boggling, with every person working some eight weeks per year just to cover the cost of compliance, paperwork and bureaucratic accountability demands. This is non-productive time. It has also stopped progressing safety. Over the last two decades, safety improvements have flat-lined (as measured in fatalities and serious injury rates, for instance) despite a vast expansion of compliance and bureaucracy.
  22. Content Article
    Safety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ‘avoiding that something goes wrong’ to ‘ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoretical and practical consequences of the new perspective on the level of day-to-day operations as well as on the level of strategic management (safety culture). Safety-I and Safety-II is written for all professionals responsible for their organisation's safety, from strategic planning on the executive level to day-to-day operations in the field. It presents the detailed and tested arguments for a transformation from protective to productive safety management.
  23. Content Article
    Charles Vincent and René Amalberti set out a system of safety strategies and interventions for managing patient safety on a day-to-day basis and improving safety over the long term. These strategies are applicable at all levels of the healthcare system from the frontline to the regulation and governance of the system. There have been many advances in patient safety, but we now need a new and broader vision that encompasses care throughout the patient’s journey. The authors argue that we need to see safety through the patient’s eyes, to consider how safety is managed in different contexts and to develop a wider strategic and practical vision in which patient safety is recast as the management of risk over time. Most safety improvement strategies aim to improve reliability and move closer toward optimal care. However, healthcare will always be under pressure and we also require ways of managing safety when conditions are difficult. We need to make more use of strategies concerned with detecting, controlling, managing and responding to risk. Strategies for managing safety in highly standardised and controlled environments are necessarily different from those in which clinicians constantly have to adapt and respond to changing circumstances.
  24. Content Article
    This report summarises the themes that emerged from a restorative process to hear from New Zealand men and women affected by surgical mesh. Restorative justice approaches and practices were used to respond to harm from surgical mesh. This innovation differs to medicolegal action and inquiry approaches in other countries. A restorative approach intended to create a safe space to explore multiple experiences and perspectives of harm.
  25. Content Article
    This 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.
×
×
  • Create New...