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Showing results for tags 'Safety culture'.
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Content ArticleUnderstanding of the significance of psychological safety has grown over recent years as we see the implications of people not speaking out—a culture that forces people to conceal rather than reveal. Concealing observations, ideas and thoughts can lead to major events that are harmful to organisations as much as individuals. Sometimes, individuals feel it is imperative to speak out somewhere, which leads to whistleblowing. This article looks at how to identify whether a workplace has a psychologically safe culture and how to transform cultures where staff don't feel able to speak up. It describes The Wellbeing and Performance Agenda, which contains six elements for building psychological safety: Transforming managers into leaders Psychological responsibility Sharing responsibility for the future success of the organisation Adaptive and positive culture Intelligent management Safe and resilient individuals
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Community PostI am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
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Community PostA question posed by a delegate at our Patient Safety Learning conference 2019: 'In a publicly funded healthcare system, what role do politicians have in setting culture and improving patient safety?' What are your thoughts?
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The patient safety leader of the future
Patient Safety Learning posted a topic in Leadership for patient safety
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One of the interesting discussions at our Patient Safety Learning Annual Conference was what do future directors of patient safety look like? What are the skills and attributes that they will possess? Andy Burrell wrote an excellent blog for the hub following this: What are you thoughts and suggestions?- Posted
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Community PostFabulous conference. Please share your take away actions and start a discussion
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World Patient Safety Day
Jayne Addison posted a topic in Improving patient safety
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Following the Patient safety Congress, World Patient Safety Day is coming up very soon, 17th September. is anyone planning to do anything in their organisation? I re call that NHS Improvement said they will be supporting this but can't see any mention of this yet on the website.- Posted
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Content ArticlePresentation slides from Nancy Redfern, Consultant Anaesthetist and Newcastle Co-chair Joint fatigue working group, and David Dawson, Consultant Anaesthetist & Sleep Physician Bradford Teaching Hospitals NHS Foundation Trust, on managing fatigue and creating a safety culture.
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Content ArticleAt a recent Patient Safety Management Network meeting, Hester Wain, Head of Patient Safety Policy at NHS England, and Dr Matt Hill, Consultant Anaesthetist, University Hospitals Plymouth NHS Trust & National Clinical Advisor on Safety Culture at NHS England, presented slides on patient safety culture. Download the presentation slides from the attachment below.
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Content ArticleImproving patient safety culture – a practical guide, developed in association with the AHSN Network, brings together existing approaches to shifting safety culture as a resource to support teams to understand their safety culture and how to approach improving it. It is intended to be used across health and social care to support everyone to improve the safety culture in their organisation or area. The guide specifically focuses on: teamwork communication just culture psychological safety promoting diversity and inclusive behaviours civility. Teams should use the guide to find a way to start to improve their culture that is most relevant to their local context. It will support teams to explore different approaches to help them to create windows into their daily work to help them to understand their local safety culture.
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Safety For All: Parliamentary Reception (13 July 2023)
Mark Hughes posted an article in Improving patient safety
This article provides an overview of a Parliamentary reception, hosted by Carolyn Harris MP, as part of the Safety for All campaign. The event was attended by over 50 guests including MPs, Peers, frontline healthcare professionals, patients and representatives from NHS organisations, regulators, charities, unions and industry.- Posted
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Content ArticleThis blog (attached below) explores how far the nature of our relationships at work have an impact on patient safety. Lesley Parkinson – the executive director of Restorative Thinking, a social enterprise working to introduce and embed restorative and relational practice in the NHS and across public sector organisations – explores how six restorative practice habits add value in multiple teams and scenarios. You can also order Lesley's book Restorative Practice at Work Six habits for improving relationships in healthcare settings.
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Content ArticleIn this article, Roger Kline looks at the responsibility of Board members in speaking up and responding to concerns raised about patient and staff safety concerns.
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Content ArticleIn a new report analysing healthcare complaint investigations, the Parliamentary and Health Service Ombudsman (PHSO) have set out the need for the NHS to do more to accept accountability and learn from mistakes in cases of avoidable harm. This blog sets out Patient Safety Learning’s reflections on this report.
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Content ArticleThere have been significant developments in patient safety over the last decade. But there is a concerning disconnect between increasing activity and progress made to embed a just and learning culture across the NHS. Recognising the challenging operational context for the NHS, this report from the Parliamentary and Health Service Ombudsman (PHSO) draws on findings from their investigations. It asks what more must be done to close the gap between ambitious patient safety objectives and the reality of frontline practice. PHSO identified 22 NHS complaint investigations closed over the past three years where they found a death was – more likely that not – avoidable. It analysed these cases for common themes and conducted in-depth interviews with the families involved.
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Content ArticleThis study in PLOS ONE assessed the frequency of adverse event reporting in Ghanaian hospitals, the patient safety culture determinants of the adverse event reporting and the implications for Ghanaian healthcare facilities. The authors found that the majority of health professionals had at least reported adverse events in the past 12 months across all 13 healthcare facilities studied. The patient safety culture dimensions were statistically significant in distinguishing between participants who frequently reported adverse events and otherwise.
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Content ArticleThis study in BMJ Open Quality aimed to assess the patient safety status in selected hospitals in Ghana. The authors concluded that the current patient safety status in the hospitals in the study was generally good, with the highest score in the knowledge and learning in the patient safety domain. Patient safety surveillance was identified as the weakest action area.
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Content Article
Why didn’t you report it? A blog by Emma Walker
Patient Safety Learning posted an article in Good practice
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Content ArticleIt is hard to separate litigation from the debate surrounding patient safety and the quality of healthcare. When we talk about developing an NHS patient safety culture, issues such as litigation and clinical negligence costs always seem to feature somewhere in discussions. In this article in the British Journal of Nursing by John Tingle, Lecturer in Law at Birmingham Law School, outlines approaches to improving patient safety in the NHS and examines the extent to which these have been driven by the desire to reduce litigation.
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Content ArticleThis review published by the Modernisation Agency explores ‘social movements’ as a new way of thinking about large-scale systems change and assesses the potential contribution of applying this new perspective to NHS improvement programmes. This review has four objectives: to explore ‘social movements’ as a new way of thinking about large-scale systems change; to assess the potential contribution of applying this new perspective to NHS improvement; to enrich and extend NHS thinking in relation to large-scale, system wide change; and to begin to establish a research and evidence base to support the emergence of an improvement movement in the NHS.
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Content ArticleThere has been growing concern about doctors’ conflicts of interests (COIs) but it is unclear what processes and tools exist to enable the consistent declaration and management of such interests. This study in the Journal of the Royal Society of Medicine mapped existing policies across a variety of organisations and settings to better understand the degree of variation and identify opportunities for improvement. The analysis of organisational policies revealed wide variation in what interests should be declared, when and how. This variation suggests that the current system may not be adequate to maintain a high level of professional integrity in all settings and that there is a need for better standardisation that reduces the risk of errors while addressing the needs of doctors, organisations and the public.
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Content ArticleIn this article, published by the British Journal of Nursing, John Tingle, Lecturer in Law, discusses recently published patient safety reports including Patient Safety Learning's Mind the Implementation Gap. Tingle concludes: "The two reports discussed here (Patient Safety Learning, 2022; Martin et al, 2023) show that 10 years after Francis (2013) there has been some improvement in NHS patient safety. This can be termed ‘measured improvement’, but this has been no big-bang trajectory. The arguments advanced in both reports need to be discussed more widely, and they provide an excellent basis for patient safety reform."
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Content ArticleThe NHS Staff Survey is an essential tool for assessing the experiences and opinions of NHS workers in Trusts in England. It also provides valuable insights to help understand the speaking up culture in the NHS. In this report the National Guardian’s Office analyse the results of the 2022 NHS Staff Survey, focusing on questions relating to speaking up.
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Content ArticleThe NHS in England has largely relied on a human resources trilogy of policies, procedures and training to improve organisational culture. Evidence from four interventions using this paradigm—disciplinary action, bullying, whistleblowing and recruitment and career progression—confirms research findings that this approach, in isolation, was never likely to be effective. Roger Kline proposes an alternative methodology, elements of which are beginning to be adopted, which is more likely to be effective and to positively contribute to organisational cultures supporting inclusion, psychological safety, staff well-being, organisational effectiveness and patient care.
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Content Article
Taming Prometheus: Talk About Safety and Culture (April 2009)
Patient_Safety_Learning posted an article in Culture
This article, published in the Annual Review of Sociology, reviews popular talk and scholarship about safety culture. -
Content Article
What is a Gemba Walk? (SSDSI)
Patient-Safety-Learning posted an article in Improving systems of care
This blog describes the Gemba Walk technique, a popular LEAN management method. During a Gemba Walk, leaders gain valuable insight into the flow of value within the organisation by visiting the workplace and interacting with employees. Leaders also learn new ways to support their employees. The approach encourages collaboration between employees and the leaders. The article covers: What is a Gemba Walk? Three important components of the Gemba Walk Gemba Walk planning, execution and follow-up Get the team ready Develop a plan Follow the Value Stream Never lose sight that the process as a problem (not the people) Keep a record of your observations Ask questions Do not suggest changes during the walk Participate in teams Who should go on a Gemba Walk? Follow up with employees Return to the Gemba An example Gemba Walk Checklist- Posted
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