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Showing results for tags 'Safety culture'.
Found 539 results
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Content ArticleSuicide rates for doctors, nurses and allied healthcare workers are rising and being involved in a safety incident increases this risk. The need to support staff when things go wrong is evident. We come to work to do the very best we can for our patients, often ignoring and at the cost of our own health. Most adverse incidents happen, not because we are bad at what we do, but because of system failure. As professionals who care passionately about our work, we blame ourselves when things go wrong. Albert Wu (2000) recognised this phenomenon and coined the term second victim. In this series of blogs I will share my own experiences of setting up and developing Safety Incident Supporting Our Staff (SISOS). In this first blog I explain the catalyst that led to developing SISOS.
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Content ArticleAlberta Health Services (AHS) is Canada’s first and largest province-wide, fully-integrated health system, responsible for delivering health services to the more than 4.3 million people living in Alberta, as well as to some residents of Saskatchewan, B.C. and the Northwest Territories.
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Content ArticleIn 2016, medical error was reported as the third greatest cause of death. The introduction of ergonomic science into healthcare will help overcome this; however, healthcare frameworks are resistant to change, particularly ergonomic initiatives. The PatientSafe Network exists to address this.
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News Article
The NHS needs a culture change to deliver safer care
Patient Safety Learning posted a news article in News
The avoidable deaths of babies and mothers in Shrewsbury and Telford Hospital Trust’s maternity services are heartbreaking. What makes them a scandal, however, is that the problems have been known about for so long, and yet the instinct of managers was to deflect and minimise. The Healthcare Commission, a forerunner to the Care Quality Commission, was concerned about injuries to babies in the trust’s maternity units as long ago as 2007. It was not until Rhiannon Davies and Richard Stanton insisted on answers about the death of their baby Kate in 2009 that the Parliamentary and Health Service Ombudsman concluded in 2013 that it had been the result of serious failings in care. Trusts need to ensure lessons stemming from failings are being implemented while patients and their families are being treated with respect and as a valuable source of feedback. Read full editorial (paywalled) Source: The Independent, 20 November 2019 -
Content Article
Human factors and ergonomics in practice (2017)
Claire Cox posted an article in Recommended books and literature
This edited book concerns the real practice of human factors and ergonomics (HF/E), conveying the perspectives and experiences of practitioners and other stakeholders in a variety of industrial sectors, organisational settings and working contexts. The book blends literature on the nature of practice with diverse and eclectic reflections from experience in a range of contexts, from healthcare to agriculture. It explores what helps and what hinders the achievement of the core goals of HF/E: improved system performance and human wellbeing. -
Content ArticlePublished by the American Association of Medical Colleges (AAMC), Quality improvement and patient safety competencies across the learning continuum is designed for: faculty medical education curricula developers residents medical school administration Designated Institutional Officials (DIOs) clinical leaders at teaching hospitals and others interested in undergraduate, graduate, and continuing medical education.
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Content Article
Patient Safety, a book by Charles Vincent
Claire Cox posted an article in Recommended books and literature
When you are ready to implement measures to improve patient safety, this is the book to consult. Charles Vincent, one of the world's pioneers in patient safety, discusses each and every aspect clearly and compellingly. He reviews the evidence of risks and harms to patients, and he provides practical guidance on implementing safer practices in healthcare. The second edition puts greater emphasis on this practical side. Examples of team based initiatives show how patient safety can be improved by changing practices, both cultural and technological, throughout whole organisations. Not only does this benefit patients, it also impacts positively on healthcare delivery, with consequent savings in the economy. Patient Safety has been praised as a gateway to understanding the subject. This second edition is more than that it is a revelation of the pervading influence of healthcare errors and a guide to how these can be overcome. -
Content ArticleThis presentation is called Families as Partners in Achieving Safer Care and is delivered in this short film by Kath Evans, Head of Patient Experience – Maternity, Newborn, Children and Young People, NHS England.
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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 the knee-jerk blame and shame approach of old.
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Content ArticleThe objective of this research paper, published in the Journal of the Royal Society of Medicine, was to investigate doctors’ intentions to raise a patient safety concern by applying the socio-psychological model ‘Theory of Planned Behaviour’.
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Content Article
Connor Sparrowhawk: The tale of laughing boy (2015)
Claire Cox posted an article in Patient stories
Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. This moving film describes what Connor was like by his friends and family and highlights the failings that caused the avoidable death of Connor. -
Content Article
Patient Safety: 20 Years After “To Err is Human” (2019)
PatientSafetyLearning Team posted an article in Culture
In this US based eMagazine Patient Safety: 20 Years after ‘To Err is Human,’ sees thought leaders from across the healthcare industry examine how shifting to patient-centred care has helped organisations across the country sustain a deeper culture of patient safety. By implementing strategies such as optimising health IT usability, advocating on behalf of patients and supporting healthcare workers, patient safety continues trending upward, leading to better outcomes. -
Content ArticleThis guidance is for all providers of health and adult social care who are registered with the Care Quality Commission (CQC) under the Health and Social Care Act 2008.
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Content ArticlePatient safety has been considered the heart of healthcare quality. This study from Najjar et al. in Safety in Health aimed to explore relationships between patient safety culture and adverse event rates at unit levels in Palestinian hospitals, and provide insight on initiatives to improve patient safety. The study confirms the idea that a more positive patient safety culture is associated with lower adverse events in hospitals at the departmental levels in Palestine. Further analysis should include a more representative sample to examine the causal relationship between patient safety culture and adverse events incidents.
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Content Article
How to do Safety-II, a blog by Steven Shorrock
Claire Cox posted an article in Techniques
The patient safety movement started almost fifteen years ago when it was energised by the release of the Institute of Medicine report “To err is human”. Despite efforts since then to improve quality and safety many believe that little progress has been made in reducing harm caused by errors, accidents and unforeseen occurrences. There is a sense of frustration with current approaches to safety (Safety I) and disappointment that more progress has not been made. Recent developments in safety science, termed Safety II, focus on resilience, adaptive capacity and complexity science and show promise for advancing the safety agenda. -
Content ArticleJenny Slayton, Executive Director of Quality Improvement for Vanderbilt University Medical Center, explains how the Vanderbilt University Medical Center has created a safety culture. Starting small, by deciding to improve handwashing, they applied what they learned from this to a range of other safety improvement opportunities.
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Content ArticleIn his blog, David Naylor from the leadership and organisational development team at The Kings Fund, discusses the importance of creating a culture where staff feel able to speak freely and challenge decisions to improve patient safety.
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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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Content ArticleIn the past decade, hospitals and healthcare workers have become more familiar with medical errors and the harm they can cause. As a result, incident investigation has become a routine part of the hospital's response to an adverse event. Armed with the results of these investigations, research and quality improvement efforts are now taking on system improvements required to create a safer healthcare environment. There has also been increased attention paid to the appropriate handling of patients and families harmed by medical errors. There is developing recognition that disclosure of adverse events is necessary if hospitals are to learn from mistakes and improve patient safety outcomes. A growing number of accrediting and licensing bodies, as well as governmental entities and professional organisations, have stated the expectation that patients should be told about harmful medical errors. However, progress has been slower in translating policy into action at the level of the frontline clinician. Are these policies also beneficial to physicians and other healthcare workers, many of whom are already struggling just to get their work done? Wu and Steckelberg discuss this further in an Editorial published in BMJ Quality and Safety.
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Content ArticleThis report describes the lack of clear roles, responsibilities and accountability for workforce planning and supply in England. In reality, this means that the health and care workforce is not growing in line with increasing population need for health and care services, and there are large numbers of vacant posts throughout the system. This impacts upon patient safety and outcomes, and leads to a challenging working environment for staff. To resolve this, the Royal College of Nursing (RCN) make the case for this to be resolved through legislation, alongside additional investment in the nursing workforce and a national health and care workforce strategy for England.
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Content ArticleFollowing the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019, chaired by Helen Hughes of Patient Safety Learning, I am pleased to share the speaker presentations on the hub. A new London conference has been announced for 29 April 2020. Telephone: 0161 376 9007; Email: info@openforumevents.co.uk for further information.
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Content ArticlePresentation from Ben Tipney and Vikki Howarth at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
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Content ArticlePromoting patient and occupational safety are two key challenges for hospitals. Recent studies have shown there are key topics that are interrelated and form a critical foundation for promoting patient and occupational safety in hospitals. So far, these topics have mainly been studied independently from each other. This study did a combined assessment of hospital staffs’ perceptions of four different topics: psychosocial working conditions leadership patient safety climate occupational safety climate.
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Content ArticlePresentation from Dr Cicely Cunningham from the Doctors' Association UK at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
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Content ArticleSafety 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.
