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Found 535 results
  1. Content Article
    Safety culture, in formal social-scientific terms, is an object of knowledge. As such, it is part of a larger discursive practice of accident prevention, together with other objects like technical failure and human error. This study examines safety culture as an object in the discourse of accident prevention based on the Foucauldian approach. 
  2. Event
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    This virtual workshop will provide participants with background theory and hands-on practice in using a multi-incident analysis to analyse a group of medication incidents that share a common topic on day 1 and introduce a novel tool called the Medication Safety Culture Indicator Matrix (MedSCIM) on day 2. Register
  3. Event
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    This virtual workshop will provide participants with background theory and hands-on practice in using a multi-incident analysis to analyse a group of medication incidents that share a common topic on day 1 and introduce a novel tool called the Medication Safety Culture Indicator Matrix (MedSCIM) on day 2. Register
  4. Content Article
    Patient safety in oncology should remain a standard indicator of quality of care and a critical objective on the EU health policy agenda as all European citizens deserve the same level of safeguarding and protection at all stages of their healthcare. Patient safety is also a critical indicator of life overall, as any irreversible or reversible patient safety issue potentially affects the quality of life. This report from the European Network for Safer Healthcare calls for 10 actions for European policy makers and national health authorities.
  5. Content Article
    The ‘No Blame Culture’ being adopted by the NHS draws attention from individuals and towards systems in the process of understanding an error. This article in the Journal of Applied Philosophy argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. The authors argue that proponents of No Blame Culture often fail to distinguish between blaming someone and holding them responsible, They examine the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, the authors argue that a responsibility culture has significant advantages over a No Blame Culture as it can enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.
  6. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Jonathan talks to us about the importance of leadership in creating a safety culture and the role of Patient Safety Learning in fostering collaboration and establishing standards for patient safety.
  7. Content Article
    Aqua recently convened a selection of expert panellists to a round table discussion, chaired by Professor Ted Baker, to consider ‘what does safety look like at a system level?’ and discuss the key issues and help support the development of Integrated Care Systems. This report captures the key themes covered in this discussion.
  8. Content Article
    The Healthcare Safety Investigation Branch (HSIB) will transition into new arms-length body The Healthcare Services Safety Investigation Body (HSSIB) in October 2023. In this article, HSSIB's Chair Designate, Ted Baker, reflects on: how the Francis Inquiry was instrumental in changing the view of patient safety in the NHS. the role of HSIB over the last five years in identifying systemic causes of patient harm. what the future holds for HSSIB.
  9. Content Article
    This report by Press Ganey outlines the key trends shaping safety culture in 2023 and makes recommendations for senior healthcare leaders to create and sustain safety culture across their organisations. Based on survey data from 814,000 US healthcare professionals, it highlights that in 2022 there was an upward trend in the perception of safety culture among clinical and nonclinical staff, but perception continues to trend downwards among senior leadership and doctors.
  10. Content Article
    Aqua recently convened a selection of expert panellists to a round table discussion, considering ‘What does safety look like at a system level?’. The round table was chaired by Professor Ted Baker, who led the discussion around the key issues facing Integrated Care Systems and how we can help support their development.
  11. Event
    Baby Lifeline has announced that their fourth annual National Maternity Safety Conference will take place on Thursday 21st September 2023 at the Hilton Metropole Hotel in Birmingham. Once again it will be focussing on learning together for a safer maternity future, building on the overwhelming success of the previous three conferences. Baby Lifeline is always keen to showcase best practice in healthcare and are pleased to welcome poster presentation abstracts again this year. They are particularly keen to hear about maternity service quality improvement measures which speak to one or more of the following themes: Listening to families and staff Promoting safety culture Teamworking Reducing mortality & morbidity. Register
  12. News Article
    US clinical and nonclinical healthcare workers have an upward-trending perception of safety culture, but physicians and leaders do not agree, according to a Press Ganey report. Press Ganey, a US company that focuses on patient satisfaction surveys, found in its annual safety culture trends report that senior management perceptions of all safety culture metrics are lower. Overall safety scores are down 0.04 points, prevention and reporting decreased 0.02 points, pride and reputation declined 0.05 points, and resources and teamwork are down 0.04 points. The report analysed 2022 data from 813,900 healthcare workers across 194 systems and 3,279 facilities. "Senior management safety culture scores are typically higher than those of operational management, suggesting a more positive perspective among those at the highest levels of provider organizations," the report said. "Yet the continued downward trajectory of senior management scores stands out as significant." Among physicians, pride and reputation fell 0.12 points. Their perceptions of overall safety declined 0.06 points, prevention and reporting is down 0.03 points, and resources and teamwork is down 0.05 points. Other healthcare employees had higher perceptions of these metrics except for pride and reputation. Also, "fewer employees today say they would recommend their organization for care than in previous years," Press Ganey found. Read full story Source: Becker's Hospital Review, 21 March 2023
  13. Content Article
    In this BMJ article, Ryan Essex and colleagues consider whether patients have more to gain than to lose from healthcare worker strikes in poorly functioning health systems Available research on the relationship between strikes and patient harm is limited and offers mixed results, most of which are not widely generalisable across different care settings, researchers said.  Overall, the researchers in the study observed a substantial decrease in the number of admissions or care visits during strikes, with broader care delivery changes varying based on who is striking. For example, when early-career physicians strike, research suggests wait times and length of stay are unaffected or become shorter.  "While patient safety obviously matters, the overly narrow framing of strikes as harmful to patients is not supported by current evidence; this also shifts focus away from the structural failings that drive strike action in the first place," "When health workers lack other avenues to enact change, failing to strike against suboptimal working conditions may actually be more harmful to patient health in the long run."
  14. Content Article
    In this blog, Patient Safety Learning looks in detail at the results of the NHS Staff Survey 2022, focusing on responses relating to reporting, speaking up and acting on safety concerns. It includes the following key points: It is difficult to imagine other safety critical industries would deem these results acceptable. Nearly half of all respondents did not feel confident their organisation would address their concerns about unsafe clinical practice. It is hugely concerning that over 40% of respondents could not say that they would be treated fairly if involved in a patient safety incident. This could significantly undermine the willingness of staff to raise concerns, with significant consequences for patient safety. There needs to be greater urgency to improve the safety culture in the health service. NHS England needs to recognise the scale of this challenge and provide clarity on how it will work with organisations to tackle this. NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS.
  15. Content Article
    This editorial in BMJ Quality & Safety argues that patients' perceptions of their safety should not be dismissed when measuring healthcare safety. The authors argue that a differentiation between ‘feeling safe’, as defined through patient experience, and ‘being safe’, as defined through observation and evaluation using clinical outcomes selected by quality experts, creates a power differential and dynamic that degrades the role and value of patient experiences as valid patient safety indicators.
  16. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Isabela shares how her experience of losing her baby daughter to avoidable harm in 2006 led to her involvement in patient safety advocacy. She talks to us about the vital role of patient campaigners in driving the movement to reduce avoidable harm, and why we need to shift from patient inclusion to belonging in order to improve patient safety.
  17. Content Article
    In a series of blogs for the hub, we will be highlighting the impact fatigue has on staff and patients. In their first blog, Emma Plunkett and Nancy Redfern, part of the Joint Working Group on Fatigue, shared how they became involved in investigating night shift fatigue, setting up the Joint Working Group on Fatigue and the aims of the #FightFatigue campaign. In this second blog, Emma and Nancy are joined by Roopa McCrossan to highlight how tiredness can impact on our performance, the patient and staff implications of fatigue, and the actions that need to be taken not only at an organisational level to improve culture, but the effort required at national level too.
  18. News Article
    An NHS England investigation into claims of a toxic culture at a hospital trust has been described as lacking transparency and undermining trust. The Parliamentary Health Service Ombudsman also said there were "very serious" patient safety issues at University Hospitals Birmingham (UHB). Criticism is contained in letters seen by the BBC between the ombudsman, the trust and NHS England. The inquiries, commissioned by the Birmingham and Solihull Integrated Care Board and the local NHS, were begun in response to an investigation by BBC Newsnight and BBC West Midlands which heard from current and former clinicians from the trust, who accused it of being "mafia-like". One of England's biggest hospital trusts, UHB has been in the spotlight for months after three probes were started following allegations doctors there were threatened for raising safety concerns. The trust denies this and says its "first priority is patient safety". The ombudsman, however, said he was sceptical about the reviews' transparency and independence. His finding of "very serious" patient safety issues at UHB is based on the trust's response to the ombudsman's recommendations and findings, including a case of an avoidable patient death. Read full story Source; BBC News, 14 March 2023
  19. Content Article
    The Association of Anaesthetists (AoA) has developed a set of resources to help NHS staff and boards tackle the impact of healthcare worker fatigue. Part of the AoA's #FightFatigue campaign, these resources can be downloaded as a whole package or separate items.
  20. Content Article
    This systematic review in the British Journal of Surgery aimed to describe types of cognitive bias in surgery, their impact on surgical performance and patient outcomes, their source, and the mitigation strategies used to reduce their effect. The authors concluded that cognitive biases have a negative impact on surgical performance and patient outcomes across all points of surgical care. This review highlights the scarcity of research investigating the sources that give rise to cognitive biases in surgery and the mitigation strategies that target these factors.
  21. News Article
    NHS staff are significantly less comfortable raising concerns and are less confident in their organisation to address them, the service’s annual staff survey has revealed. The 2022 results, with a response rate of 46%, showed a decline on all measures relating to raising concerns about clinical safety and speaking up more generally, with the greatest deterioration seen in the percentage of staff who would feel secure raising concerns about unsafe clinical practice. Helen Hughes, chief executive of charity Patient Safety Learning, warned an “alarmingly high” number of staff could not say they felt safe raising concerns. Ms Hughes continued: “If we are to effectively learn from and prevent future incidents of avoidable harm, staff need to feel safe to raise and discuss patient safety incidents. “This year’s staff survey results are a clear indication that too often this is still not the case. This is reinforced by the experiences and testimonies of many whistleblowers and the findings of numerous inquiries into major patient safety scandals.” She added there were a lack of “tangible measures” in place to create a safety culture where staff feel safe to speak up and called for “more resources to support improvement and evaluate their impact”. Read full story (paywalled) Source: HSJ, 9 March 2023
  22. News Article
    Which trusts receive the highest recommendations from staff as a place to work? HSJ has analysed the full results of today’s 2022 NHS Staff Survey for general acute and acute/community trusts. HSJ has also analysed the results for mental health trusts and ambulance and community trusts. More than 630,000 staff responded to the NHS staff survey between September and December 2022 – a 46% response rate, down from 48% in 2021. Nationally, across all trust types, 57.4% said they would recommend their organisation as a place to work in 2022. That was down from 59.4% in 2021, and from 63.4% in 2019. Read full story (paywalled) Source: HSJ, 9 March 2023
  23. Content Article
    The NHS Staff Survey is one of the largest workforce surveys in the world and is carried out every year to improve staff experiences across the NHS. It asks staff in England about their experiences of working for their respective NHS organisations. 636,384 staff responded to the survey in 2022. The full results of the 2022 NHS Staff Survey are published on the NHS Staff Survey website.
  24. Event
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    Despite decades of attention to safety, the 2023 New England Journal of Medicine article titled "The Safety of Inpatient Health Care" ushers in a stark reminder that patients continue to experience unacceptably frequent, and often serious, harms while receiving care. This 2023 IHI Patient Safety Awareness Week free webinar features lead author and globally renown safety expert, Dr. David Bates, who will share perspective on the history of harm in health care, key findings, and insights from this recent publication, associated opportunities to improve identification and measurement of events, and methods for anticipating and preventing harm. Whether you’re a health care leader, safety or quality professional, direct care provider, or work in any setting or role in health care, you’ll leave this illuminating discussion with refreshed thinking about what’s essential for a radical reboot of safety and the role that you and your organizations can take to eliminate and prevent harm. Register
  25. Content Article
    This document outlines the identity and strategy of the European Patient Safety Foundation (EPSF), an independent, public interest foundation based in Belgium.
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