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Showing results for tags 'Safety culture'.
Found 535 results
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Content ArticleA blog published in Safety & Health on how you can leverage shift supervisors to ensure consistent safety knowledge among frontline workers. Although not specific to healthcare the examples can be applied to frontline healthcare workers.
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The Patient Safety Learning hub has provided the vehicle through which I’ve shared my personal journey as I sought to establish and embed a second victim support initiative at the trust where I worked until my recent retirement. Four years ago SISOS was set up to ensure that colleagues affected by safety incidents received emotional support as soon as possible. A lot of lessons have been learned along the way and positive actions taken. These are my personal thoughts. -
Content ArticleThis report from Verita, an independent consultancy, provides an independent account into the disciplinary process regarding Nurse Amin Abdullah in late 2015. It was commissioned by Imperial College Healthcare NHS Trust (‘the trust’) in 2017 to review the process that it followed in dealing with Nurse Abdullah’s case and whether fair and appropriate action was taken
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Content ArticleWhile there is growing awareness of the risk of harm in ambulatory health care, most patient safety efforts have focused on the inpatient setting. The Comprehensive Unit-based Safety Program (CUSP) has been an integral part of highly successful safety efforts in inpatient settings. In 2014 CUSP was implemented in an academic primary care practice. As part of CUSP implementation, staff and clinicians underwent training on the science of safety and completed a two-question safety assessment survey to identify safety concerns in the practice. The concerns identified by team members were used to select two initial safety priorities. The impact of CUSP on safety climate and teamwork was assessed through a pre-post comparison of results on the validated Safety Attitudes Questionnaire. CUSP is a promising tool to improve safety climate and to identify and address safety concerns within ambulatory health care.
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Content ArticleA culture of teamwork and learning from mistakes are universally acknowledged as essential factors to improve patient safety. Both are part of the Comprehensive Unit-based Safety Program (CUSP), which improved safety in intensive care units but had not been evaluated in other inpatient settings.
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Content ArticleThe Comprehensive Unit-based Safety Program (CUSP) aims to improve the culture of safety while providing frontline caregivers with the tools and support that they need to identify and tackle the hazards that threaten their patients at the unit or clinic level. Developed by Johns Hopkins safety and quality researchers, the five-step programme has been used to target a wide range of hazards, including patient falls, hospital-acquired infections, medication administration errors, specimen labeling errors and teamwork and communication breakdowns. Notably, CUSP has been used in national and international quality improvement projects that have drastically reduced hospital-acquired infections. Whether your hospital has participated in such projects or is seeking to adopt CUSP, the Armstrong Institute provides resources to help you run a successful programme.
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Content ArticleAnnie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without a blame and shame approach.
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Content ArticleSince January 2019, the Health Information and Quality Authority (HIQA) has been the competent authority for regulating medical exposure to ionising radiation in Ireland and receives incident notifications of significant events arising from accidental or unintended medical exposures. As part of its role, HIQA is responsible for sharing lessons learned from significant events. HIQA has published an overview report on the lessons learned from notifications of significant incident events in Ireland arising from accidental or unintended medical exposures in 2019. This report provides an overview of the findings from these notifications and aims to share learnings from the investigations of these incidents.
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Content ArticleThis survey, a collaboration between the International Society for Quality in Healthcare (ISQua) and the International Hospital Federation (IHF) was designed to frame the WHO Global Consultation on Patient Safety, which was held from 24-26 February 2020 to kick off the development of the Global Patient Safety Action Plan. Already then, the pandemic-to-be was affecting various regions, before striking health systems worldwide. The question of patient safety is a critical one in the discussion about COVID-19: hygiene and hospital-acquired infections, non-suitable hospital architecture, delayed surgeries and procedures, lack of personal protective equipment (PPE) and much more affected the safety of patients as well as of health workers, to whom the World Patient Safety Day 2020 is dedicated. In February 2020, the IHF disseminated a short survey on national safety plans to its Full Members, hospitals’ national/regional representatives. At the same time, ISQua disseminated their survey asking how well incident reporting is in place, and if the outcomes improve the 'no blame no shame' approach to their Individual and Institutional Members. The surveys were repeated in July 2020 to see if the onset of COVID-19 had made any positive or negative changes to the responses.
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Medical error prevention (5 May 2020)
Sam posted an article in Good practice
Medical errors are a serious public health problem and a leading cause of death in the United States. It is a difficult problem as it is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimises the chances of a recurrent event. By recognising untoward events occur, learning from them, and working toward preventing them, patient safety can be improved. Part of the solution is to maintain a culture that works toward recognising safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organisations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers. -
Content ArticleThis study from Clay-Williams et al., published in the International Journal for Quality in Healthcare, aimed to explore the associations between the organisation-level quality arrangements, improvement and implementation and department-level safety culture and leadership measures across 32 large Australian hospitals. The authors found that the influence of organisation-level quality management systems on clinician safety culture and leadership varied depending on the hospital department, suggesting that whilst there was some consistency on patient safety attitudes and behaviours throughout the organizations, there were also other factors at play.
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Content ArticleIn advance of the second annual World Patient Safety Day on 17 September 2020, the theme of which is Health Worker Safety: A Priority for Patient Safety’, this blog from Patient Safety Learning looks at how staff safety relates to patient safety.
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Content ArticleOn Thursday 30 July 2020, NHS England and NHS Improvement published the NHS People Plan for 2020/21. Building on the Interim NHS People Plan released in 2019, it describes itself as focusing on “how we must all continue to look after each other and foster a culture of inclusion and belonging, as well as action to grow our workforce, train our people, and work together differently to deliver patient care”. In this blog, Patient Safety Learning looks at the People Plan with specific reference to its approach to tackling the blame culture in the NHS, which is a significant factor in the safety of patients and staff. It highlights where we think the People Plan has not addressed these well-known concerns and what more needs to be done urgently.
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Content ArticleDr Michael Leonard and Dr Allan Frankel explore how effective leadership and organisational fairness are essential for patient safety within healthcare services. They discuss how leaders can influence their organisations to help create a robust safety culture.
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Is doing nothing, doing no harm?
Dr Mark Lomax posted an article in How to engage for patient safety
Dr Mark Lomax, CEO of PEP Health, the social listening tool of patients, talks about the lack of discussion following the “First Do No Harm” Cumberlege Report and why patient safety and experience should be viewed differently. -
Content ArticleLack of transparency helped Ian Paterson to operate unchecked for years, according to inquiry The recent report of the Paterson Inquiry identified multiple levels of dysfunction across England’s health system. These allowed surgeon Ian Paterson to practise unchecked for many years, causing serious harm to thousands of patients. Among the less surprising of the failings is the lack of transparency in reporting activity and outcomes by the private hospitals where he worked. As the report notes, transparency is no panacea, but it is essential for protecting patients from harm. This BMJ editorial argues that urgent action is now needed to improve reporting by independent sector providers to bring them in line with standards in the NHS.
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Content ArticleIn this blog, David Provan discusses the impact asking questions as safety professionals gleans more insight and improves engagement with staff rather then 'telling' them how to improve safety. David is Managing Director Forge Works, Adjunct Fellow Griffith University and host of The Safety of Work podcast.
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Content ArticleHow work gets done in complex healthcare systems is ethically important. When healthcare professionals and other staff are pressured to improvise, fix structural problems, or comply with competing policies, the uncertainty and distress they experience have potential consequences for patients, families, colleagues, and the system itself. This book presents a new theory of healthcare ethics that is grounded in the nature of healthcare work and how it is shaped by the ever-changing conditions of complex systems, in particular, problems of safety and harm. By exploring workarounds and other improvised practices in complex healthcare systems that are difficult for professionals to talk about openly, yet have unclear effects, including their value or risk to patients, this book offers a realistic look at our changing healthcare system and how we can improve the way we manage moral problems arising in the care of the sick. Berlinger argues that healthcare ethics in complex and changing healthcare systems should reflect the moral complexity of healthcare work, analyse common ethical challenges with reference to behaviours and pressures driven by the system itself and support opportunities for healthcare professionals and staff at all levels to reflect on the problems they face and to take part in social change. The book's chapters include frameworks for looking at ethical challenges in healthcare as problems of safety and harm with consequences for patients. Are Workarounds Ethical? is designed to support clinician education in medicine, nursing, and interdisciplinary contexts and recommend methods for integrating ethics, safety, and justice in practice.
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Make or Break: Incivility in the workplace (ESTH, 2019)
Claire Cox posted an article in Motivating staff
See how incivility affects all of us in the NHS and how that can impact patient safety. Join the staff of Epsom and St Helier University Hospitals NHS Trust on their journey as they reflect on the real-life effects of both incivility and active kindness. This video was devised, filmed and produced by the Elena Power Simulation Centre. -
Content ArticleIn healthcare systems safety needs to be conceived in a relational as well as a regulatory framework, with resilience being understood as the interplay between both elements. This presentation from the Australian Institute of Health Innovation, critically appraises how harm is understood and responded to within the New Zealand health system and the potential contribution of restorative responses. A major and internationally unprecedented project, that employed a restorative approach to address the harm caused to patients and professionals by the use of surgical mesh in New Zealand (NZ), is used to illustrate the case for change.
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Content ArticleIn this talk, Steven Shorrock outlines seven fallacies of work-as-imagined, concerning outcomes happen, how people work, how we design and implement, and how we think. A number of examples provided by healthcare workers are given. The talk was given at the HSJ Patient Safety Congress 2019.
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Content ArticleReport from the Saudi Patient Safety Center on: 1. Hospital Survey on Patient Safety Culture National Recommendations Cycle 2: (2019), and 2. National Supplementary Recommendations related to COVID-19.
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Patient Safety Resource Guide (US Department of Defence)
Claire Cox posted an article in Safety culture programmes
The Department of Defence (DoD) Patient Safety Program's Resource Guide was developed to engage, educate and equip readers with products, services, tools and solutions to help ensure the safe delivery of health care in the Military Health System. This comprehensive 18-page guide includes: Training and enrollment information for patient safety champions and facilities interested in teamwork using the TeamSTEPPS Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based teamwork system designed to improve the quality, safety and efficiency of healthcare. TeamSTEPPS consists of a collection of instructions, materials and tools to help drive a successful teamwork initiative from the initial planning to implementation through to sustainment. The system is designed to improve patient safety using a three-phase approach: Phase I Assessment: Facility determines organisational readiness; Phase II Planning, Training & Implementation: Facility “decides what to do” and “makes it happen;” and Phase III Sustainment: Facility spreads the improvements in teamwork performance, clinical processes and outcomes resulting from the TeamSTEPPS initiative.TeamSTEPPS method. Learning opportunities for commanders, leaders, providers and patients. Information about the measurement and reporting of events that could cause harm to patients and how to apply changes through documented studies. Online DoD PSP and partner resources and publications. An overview of continuing education credit-eligible learning opportunities offered by the DoD PSP. -
Content ArticleUnsafe healthcare is a well-recognised issue internationally and is attracting attention in India as well. Drawing upon the various efforts that have been made to address this issue in India and abroad, Madock et al. explore how we can accelerate developments and build a culture of patient safety in the Indian health sector. Using five international case studies, the authors describe the experiences of promoting patient safety in various ways to inform future developments in India. The authors offer a roadmap for 2020, which contains suggestions on how India could build a culture of patient safety
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Content ArticleIn this article, published by the BMJ, Professor Russell Mannion and Professor Huw Davies explore how notions of culture relate to service performance, quality, safety and improvement.
