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Found 539 results
  1. Content Article
    Over the last two decades across the globe we have seen a multitude of programmes, projects and books to help improve the safety of patient care in healthcare. However, the full potential of these has not yet been reached. Most of the current approaches are top down, programmatic and target driven. These look at problems in isolation one harm at a time with simplistic solutions that fail to support a holistic, systematic approach. They are focused on collecting incident data and learning from failure using tools that are not fit for purpose in a complex nonlinear system. Very rarely do the solutions help build the conditions, cultures and behaviours that support a safer system and help the people involved work safely. This book uniquely combines the latest thinking in safety, including creating a balanced approach to learning from what works as a way to understand why it fails, together with the evidence on building a just culture, positive workplaces and working relationships that we now know are so important for safety. This book builds on the author’s first book Rethinking Patient Safety which exposed what we need to do differently to truly transform our approach to patient safety. It updates the reader further on the concepts explored in the first book but also vitally helps readers understand the ‘how’.
  2. Content Article
    England’s 15 Patient Safety Collaboratives (PSCs) play an essential role in identifying and spreading safer care initiatives from within the NHS and industry, ensuring these are shared and implemented throughout the system. The PSC is a joint initiative, funded and nationally coordinated by NHS Improvement, with the regional PSCs organised and delivered locally by the Academic Health Science Networks (AHSNs).
  3. Content Article
    The Care Quality Commission (CGC) is the independent regulator of health and adult social care in England. They make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve.  Independent acute hospitals play an important role in delivering healthcare services in England, providing a range of services, including surgery, diagnostics and medical care. As the independent regulator, the CQC, hold all providers of healthcare to the same standards, regardless of how they are funded. 
  4. Content Article
    There is a growing body of evidence to demonstrate that health professionals feel emotionally distressed after a patient safety incident and there is an emerging recognition of the potential negative impact on both the health professionals’ health and on patient safety.  The Canadian Institute for Patient Safety partnered with the Mental Health Commission of Canada to develop a new toolkit for peer-to-peer support programmes in healthcare.  It includes tools, resources and templates from organisations across the globe who have successfully implemented their own peer support programmes for healthcare providers, and is intended for policy makers and regulators, administrators, managers, healthcare teams and peer supporters. 
  5. Content Article
    This extensive resource, by the Canadian Patient Safety Institute, based on evidence and leading practices, helps patients and families, patient partners, providers, and leaders work together more effectively to improve patient safety.  The Institute states that collaboratively, we can more proactively identify risks, better support those involved in an incident, and help prevent similar incidents from occurring in the future.
  6. Content Article
    This 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.
  7. Content Article
    Last year, the Canadian Patient Safety Institute (CPSI) launched a safety improvement project focused on the Measurement and Monitoring of Safety. The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety and helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.
  8. Content Article
    An adverse clinical event, patient safety incident or medical error can have a far-reaching impact not only for the patient and their families, the 'first victims', but also the healthcare professionals involved. These are sometimes referred to as ‘second victims’. Often there are few opportunities for second victim healthcare professionals to discuss the details of incidents or events and share how this has affected them personally. The East Midlands Patient Safety Collaborative (EMPSC) funded the University of Leicester as part of their National Safety Culture workstream to develop a Second Victim Support Unit within the Children’s Hospital at University Hospitals Leicester to test whether models of support established in the US could be successfully transferred to UK health settings.
  9. Content Article
    Dr 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.
  10. Content Article
    The University of Missouri Health Care (MUHC), an academic healthcare system located in Columbia, Missouri, USA, deployed an evidence-based emotional support structure for second victims based on research with recovering second victims. MUHC is a six-hospital healthcare system with 52 ambulatory clinics and approximately 6,500 employees. The second victim support structure, known as the forYOU Team, was designed to increase awareness of the second victim phenomenon, “normalise” the psychological and physical impacts, provide real-time surveillance for possible second victims within clinical settings, and render immediate peer-to-peer emotional support when a potential second victim is identified. This article published in Patient Safety & Quality analyses the success of the programme.
  11. Content Article
    The NHS Long Term Plan highlighted several safety issues that need to be addressed: the fear of blame and retribution which curtails reporting and learning, lack of staff understanding of patient safety matters and workforce issues. This short article summarises what I have learnt about how After Action Review (AAR) can directly address the first two of these and indirectly impact on the third. 
  12. Content Article
    PatientSafe Network in Australia has been promoting the theatre cap challenge across the world. By wearing your name on your theatre cap it can improve team work and patient safety. The PatientSafe Network is a registered non for profit charity. It has been developed by front line healthcare staff and is for anyone to use – patients, relatives, doctors, nurses, pharmacists, healthcare managers, equipment and system developers, insurers – who wants to improve patient safety.
  13. Content Article
    How can leaders ― with or without formal authority ― create psychological safety in healthcare? In this short video, Amy Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, describes three key actions to foster a psychologically safe work environment.
  14. Content Article
    Strengthening a safety culture necessitates interventions that simultaneously enable, enact and elaborate in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The 'Bundle' is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture.
  15. Content Article
    Near misses or good catches present organisations with learning opportunities. Using data comparisons run by the Pennsylvania Patient Safety Authority, this article by Wallace et al. highlights how good catch programmes can contribute to significant reductions in harmful events and offers insights from risk managers and patient safety officers regarding elements that are necessary to establish successful good catch initiatives and the culture to support them.
  16. Content Article
    What patient safety beliefs get in the way of preventing harm? In this video, the Institute for Healthcare Improvement's (IHI) Frank Federico lists some common misunderstandings, including the tendency to think of the Institute of Medicine’s six quality aims for improvement in silos.
  17. Content Article
    Analysis of the New England Journal of Medicine (NEJM) Catalyst Insights Council Survey on organisational culture.
  18. Content Article
    Hamblin-Brown and Ingram, in the Journal of Patient Safety and Risk Management, discuss how Aspen Healthcare have reduced patient harm by engaging staff in ‘STEP-up’: a programme to improve the culture of patient safety. 
  19. Content Article
    Designed and tested by the Institute of Healthcare Improvement (IHI)’s world-renowned safety experts, the Patient Safety Essentials Toolkit can help you improve teamwork and communication, understand the underlying issues that can cause errors, and create and maintain reliable systems. IHI's Vice President, Frank Federico, helped develop the contents of the new toolkit. In the following interview, he provides an overview of how to put the toolkit to good use.
  20. Content Article
    The Royal College of Emergency Medicine has developed The Safety Toolkit which aims to describe the structures, processes and skills required for a ‘safe’ department. There are resources identified within each section to stimulate, provoke and challenge, as well as guide personal development. There are overlapping references and differing perspectives but the vision is of a resource for change and development.
  21. Content Article
    This document sets out the General Medical Council's (GMC) expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety. 
  22. Content Article
    Established by Health Canada in 2003, the Canadian Patient Safety Institute (CPSI) works with governments, health organisations, leaders and healthcare providers to inspire extraordinary improvement in patient safety and quality. SHIFT to Safety is a major shift to empower staff with the tools and information they need to keep patients safe, at any level.
  23. Content Article
    In 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.
  24. Content Article
    Empowering doctors to speak up when they have concerns is essential to making our NHS safer, say Peter Brennan and Mike Davidson in this BMJ article. They discuss how healthcare can learn a lot from aviation and other high risk organisations, particularly in how they’ve embraced and applied human factors, the importance of looking after ourselves at work, and reducing hierarchy.
  25. Content Article
    This is South Australia patient Safety Report for 2017. South Australia Health is committed to creating and maintaining a sustainable quality environment which provides services that are consumer centred, driven by information and organised by safety , by ensuring that: patients can get care when they need it healthcare staff respect and respond to patient choices, needs and values partnerships are formed between patients, their family, carers and healthcare providers up-to-date knowledge and evidence is used to guide decisions about care safety and quality data is collected, analysed and fed back for improvement action is taken to improve patients’ experience safety is made a central feature of how healthcare facilities are run, how staff work and how funding is organised.
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