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Showing results for tags 'Safety culture'.
Found 539 results
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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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Patient safety in oral surgery
PatientSafetyLearning Team posted an article in Dentist
This article from the British Association of Oral Surgeons (BAOS) highlights that these clinicians perform a high volume of multi-site complex procedures, on anxious patients who are frequently conscious, that have the potential for error to occur. -
Content ArticleAll healthcare professionals have a duty of candour – a professional responsibility to be honest with patients when things go wrong. This is described in 'The professional duty of candour', which introduces this guidance and forms part of a joint statement from eight regulators of healthcare professionals in the UK. This guidance from the Nursing and Midwifery Council complements the joint statement from the healthcare regulators and gives more information about how to follow the duty of candour principles.
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Second victim support for managers
Patient Safety Learning posted an article in Second victim
This second victim support website was designed as a resource for clinicians who are involved in a patient safety incident, their colleagues and the organisations they work for. It has been developed by a team from the Yorkshire Quality and Safety Research Group and the Improvement Academy. It is supported by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre. -
Content ArticlePatients have different concerns from clinicians when asked about problems with their care, and may identify preventable safety issues. When trained volunteers surveyed 2,471 patients from three NHS Trusts in England, 23% of patients identified concerns about their care. The biggest category of concerns related to communication, with staffing issues and ward environment the next most common and safety issues. Although the majority of safety issues were categorised as negligible or minor, they were also seen as definitely or probably preventable. Patient-reported concerns identified new areas which may not have been picked up by staff, such as fear of other patients or delays in procedures. This is one of the largest studies to look at patient safety concerns from the patient perspective. This study suggests that inpatient surveys can identify patient safety issues and that collecting this data could help trusts identify areas where patient experience could be improved. However, for the data to be useful, it needs to be routinely collected, reviewed and acted upon, which may be difficult to implement.
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Content ArticleThis presentation, delivered by Margaret Murphy, Lead Advisor for the World Health Organization, took place at the Patient Safety Learning conference. In this short video, Margaret argues that the hear of the matter is in the patient'd and families experiences of care and how this, alongside true engagement, can be used to drive improvement.
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Content ArticleThis joint report by the Prison Reform Trust (PRT), INQUEST and Pact (the Prison Advice and Care Trust) reveals that most prisons in England and Wales are failing in their duty to ensure that emergency phone lines are in place for families to share urgent concerns about self-harm and suicide risks of relatives in prison. This is in serious breach of government policy that families should be able to share concerns ‘without delay’.
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Content ArticleSam Morrish, a three-year-old boy, died from sepsis on 23 December 2010. An investigation, undertaken by the Parliamentary and Health Service Ombudsmen (PSHO) in 2014, found that had Sam received appropriate care and treatment, he would have survived. Yet, previous NHS investigations failed to uncover that his death was avoidable. So the family asked PSHO to undertake a second investigation to find out why the NHS was unable to give them the answers they deserved after the tragic death of their son.
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Civility Saves Lives
PatientSafetyLearning Team posted an article in Good practice
Civility Saves Lives are a collective voice for the importance of respect, professional courtesy and valuing each other. They aim to raise awareness of the negative impact that rudeness (incivility) can have in healthcare, so that we can understand the impact of our behaviours. Their goal is to disseminate the science of the impact of incivility in healthcare. They also strive to research and collaborate on data about the impact of incivility. -
Content ArticleThis evidence scan provides a brief overview of some of the tools available to measure safety culture and climate in healthcare. Safety culture refers to the way patient safety is thought about and implemented within an organisation and the structures and processes in place to support this. Safety climate is a subset of broader culture and refers to staff attitudes about patient safety within the organisation. Measuring safety culture or climate is important because the culture of an organisation and the attitudes of teams have been found to influence patient safety outcomes and these measures can be used to monitor change over time. It may be easier to measure safety climate than safety culture.
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No blame culture, a blog by Joanne Hughes
PatientSafetyLearning Team posted an article in Bullying and fear
In this powerful blog, based on her personal experience of losing a child, Joanne Hughes argues you can (and should) identify and blame the error, the 'act or omission’ for the harm, but very often it is not appropriate or fair to blame the 'person' who carried out that act. Avoidably grieving parents, she highlights, do need to know 'what' is to blame and 'why' it occurred. -
Content ArticleSeveral organisations, researchers and clinicians have discussed the need for a patient safety culture in dentistry. Strategies are available to help improve patient safety in healthcare and deserve further consideration in dentistry. Published by the British Dentistry Journal, this article: discusses the history of patient safety initiatives in healthcare and dentistry describes strategies that can be applied to identify patient safety issues in dentistry emphasises the importance of both process and cultural factors in developing a safer healthcare environment.
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Content ArticleWhen the Harvard Business Review (HBR) asked Robert Sutton for suggestions for its annual list of Breakthrough Ideas, he told them that the best business practice he knew of was 'the no asshole rule'. Sutton's piece became one of the most popular articles ever to appear in the HBR. Spurred on by the fear and despair that people expressed and the tricks they used to survive with dignity, Sutton was persuaded to write this book. He believes passionately that civilised workplaces are not a naive dream, that they do exist, do bolster performance and that widespread contempt can be erased and replaced with mutual respect when a team or organisation is managed right. There is a huge temptation by executives and those in positions of authority to overlook this trait especially when exhibited by so-called producers, but Sutton shows how overall productivity suffers when the workplace is subjected to this kind of stress.
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Content ArticleIncivility chips away at people, organisations, and our economy. Slights, insensitivities, and rude behaviors can cut deeply. Moreover, incivility hijacks focus. Even if people want to perform well, they can't. Customers too are less likely to buy from a company with an employee who is perceived as rude. In this book, Christine Porath shows how people can enhance their influence and effectiveness with civility. Combining scientific research with fascinating evidence from popular culture and fields such as neuroscience, medicine, and psychology, this book reminds managers and employers what they can do right now to improve the quality of their workplaces.
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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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Content ArticleIn this third blog of the series, I will discuss how I went about setting up a calm space as part of Chase Farm Hospital's Safety Incident Supporting Our Staff (SISOS) initiative. This allows staff to go and rest and get support if needed.
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Content ArticleThis 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.
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Content ArticleMy previous blog talked about how the idea for SISOS (Safety Incident Supporting Our Staff) – an initiative to support staff involved in safety incidents – came about at Chase Farm Hospital. The SISOS team provide confidential, emotional support in a safe environment and make other support, including professional help more easily accessible. It is important to recognise that we are 'Listeners' and not professional counsellors. My second blog continues this journey.
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Content ArticleECRI Institute's mission is to protect patients from unsafe and ineffective medical technologies and practices. More than 5,000 healthcare institutions and systems worldwide, including four out of every five U.S. hospitals, rely on ECRI Institute to guide their operational and strategic decisions.
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Content ArticleIn his blog for Aish.com, Rabbi Efrem Goldberg talks about the power of a sincere apology and how this can be translated into medical care settings.
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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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From Safety-I to Safety-II: A White Paper (2015)
PatientSafetyLearning Team posted an article in Organisational
This White Paper, published by the authors, helps explains the key differences between, and implications of, two ways of thinking about safety (Safety-I and Safety-II). -
Content ArticleThe current approach to patient safety, labelled Safety-I, is predicated on a ‘find and fix’ model. It identifies things going wrong, after the event, and aims to stamp them out, in order to ensure that the number of errors is as low as possible. Healthcare is much more complex than such a linear model suggests. This article, published by the International Journal for Quality in Health Care, argues that we need to switch the focus to what we have come to call Safety-II, a concerted effort to enable things to go right more often. The key is to appreciate that healthcare is resilient to a large extent, and everyday performance succeeds much more often than it fails.
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Caring for doctors, caring for patients (November 2019)
Claire Cox posted an article in Workforce and resources
Patient safety depends on doctors’ well-being. Medicine is a tough job, but it's made it far harder than it should be by neglecting the simple basics in caring for doctors’ well-being. The well-being of doctors is vital because there is abundant evidence that workplace stress in healthcare organisations affects quality of care for patients as well as doctors’ own health. In 2018 the General Medical Council asked Professor Michael West and Dame Denise Coia to carry out a UK-wide review into the factors which impact on the mental health and well-being of medical students and doctors. The detailed practical proposals in this report provide a road map to health service leaders faced with the challenge of developing healthy and sustainable workforces. -
Content ArticleThere is widespread recognition that creating a safety culture supports high-quality health care. However, the complex factors affecting cultural change interventions are not well understood. This study by McKenzie et al., published in The Joint Commission Journal of Quality and Patient Safety, examines factors influencing the implementation of an intervention to promote professionalism and build a safety culture at an Australian hospital.
