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Showing results for tags 'Safety culture'.
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Content ArticleThis framework produced by the Royal College of Paediatrics and Child Health (RCPCH) aims to improve how healthcare organisations recognise and respond to children at risk of deterioration. A safer system can work in partnership with families and patients, develop a patient safety culture and support ongoing learning. The framework covers: Patient safety culture Partnership with families Recognising deterioration Responding to deterioriation Open and consistent learning Education and training
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News Article
Rotherham NHS Foundation Trust fined for exposing babies to 'serious harm'
Patient Safety Learning posted a news article in News
A hospital trust has been fined £200,000 for putting four babies at "serious risk"of harm. Staff at Rotherham Hospital failed to spot non-accidental injuries during admissions, Sheffield Magistrates' Court heard. District Judge Naomi Redhouse criticised failures in the hospital's systems and processes. Health watchdog, the Care Quality Commission (CQC), had earlier highlighted problems with safeguarding training at the trust prior to the babies' admissions between January 2019 and February 2020. The court was told how one eight-day-old baby was brought into the hospital on 23 December 2019 suffering from breathing difficulties and bleeding from the nose and mouth. It was only on the child's fifth visit to hospital - after a GP raised concerns - that a child safety examination took place, revealing rib and leg fractures that were deemed non-accidental. Ms Redhouse also heard how a month-old baby brought in with a mouth injury on 20 January 2019 was on a child protection plan but this was not spotted by the paediatric nurse who examined the baby. This child was twice released from hospital, with no safeguarding concerns, before a scan and other examinations revealed multiple fractures, the court heard. Prosecutor Ryan Donohue said failings had been identified in areas including policy implementation, training, reporting, auditing and governance. Eleanor Sanderson, mitigating for the trust, said: "The trust wishes to express to the court its deep regret for the circumstances which gave rise to these offences and the risk posed to those who required safeguarding." Read full story Source: BBC News, 26 October 2022 -
Content ArticleThis article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
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Content ArticleThe Health and Care Act 2022 will establish the Healthcare Safety Investigations Branch (HSIB) as the Health Services Safety Investigations Body (HSSIB) in April 2023, a fully independent arm’s-length body. This blog by Dr Sean Weaver, Deputy Medical Director at HSIB, outlines what HSSIB's new powers will be.
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Content ArticlePreventable harm, from the systems of care intended to improve health, continues to occur at an unacceptable rate in the United States. Healthcare systems have an opportunity to learn and improve from each episode of preventable harm. Accordingly, every preventable patient death or injury must energise our efforts to prevent future patient harm. The Anesthesia Patient Safety Foundation (APSF) believes that criminal prosecution of healthcare providers will make the work of preventing harm more difficult since it continues to shift the focus away from system improvements. They have released a position and policy statement outlining the rationale for opposing criminal prosecution and, equally important, recommends that all healthcare systems and organisations aggressively act, now, to improve their culture, processes, and training to reduce errors of all kinds and, specifically in light of recent events, medication errors. Some specific actions are recommended as examples of what can be done. Individual healthcare professionals should be mindful of their role in preventing errors and reporting errors that occur as well as taking action to encourage and enable their organization to improve the flaws in the systems in which they work that lead to harm to patients.
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Content ArticleThis open access book addresses the future of work and industry by 2040—a core interest for many disciplines inspiring a strong momentum for employment and training within the industrial world. The future of industrial safety in terms of technological risk-management, although of obvious concern to international actors in various industries, has been quite sparsely addressed. This brief reflects the viewpoints of experts who come from different academic disciplines and various sectors such as oil and gas, energy, transportation, and the digital and even the military worlds, as expressed in debates and discussions during a two-day international seminar. 'Managing future challenges for safety' will interest and influence researchers considering the future effects of a number of currently developing technologies and their practitioner counterparts working in industry and regulation.
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Content ArticleFor two decades, Swiss Cheese theory has been an influential metaphor in safety science and accident prevention. It has made barrier theory and the impact of safety culture on operational safety more understandable to the upper echelons of high-risk organisations in many industrial sectors. Yet sometimes the Swiss Cheese model is used to focus on the operational ‘sharp end’ and unsafe acts, like a magnifying glass that acknowledges organizational influence, but still targets the human operator. It is time to ‘turn this lens around and allow organisations to focus on the upstream factors and decision-making that can engender these unsafe acts in the first place. This paper reports on an approach to do this, under development in the Maritime sector, called Reverse Swiss Cheese.
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Content ArticleLearning from mistakes generally is considered the upside to failure. But in healthcare, where staff members regularly face stressors and systemic issues that impede a strong culture of safety, creating that standard can be difficult. To understand why medical mistakes and care complications occur repeatedly Becker's spoke with Patricia McGaffigan, vice president of safety programmes for the Institute for Healthcare Improvement. Ms. McGaffigan outlined three factors that contribute to repeat medical errors, care complications or lost progress on quality improvement initiatives: A "whack-a-mole" approach to safety. Lack of focus on systemwide changes. Unhealthy or unsafe work environments.
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Content Article
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In this blog, Lotty Tizzard, Patient Safety Learning's Content and Engagement Manager, writes about a recent experience taking her son to a local walk-in centre. She describes the negative response she received when asking questions about her son's treatment, and considers the potentially dangerous consequences of patients and parents being disempowered to fully understand and contribute to their own, or their children's, care. -
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. Sarah and Jaydee are working on an innovative project at NHS Dorset Integrated Care Board (ICB) to ensure general practice is a central part of improving patient safety across services. They talk about the value and challenges of collaborative working, how they are tailoring their offer to fit the needs of local GP practices, and making patient safety a core part of training for all healthcare professionals. -
Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
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Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views? -
Content ArticlePolypharmacy refers to the prescription of many medicines to one patient. As more people live longer with multiple long-term conditions, the number of medicines they take often increases. This can have a significant burden on the person managing and trying to adhere to multiple medicines regimes, and can also be harmful. The Academic Health Science Networks (AHSN) Network's Polypharmacy Programme aims to support healthcare professionals to identify patients at potential risk from polypharmacy, and to support better conversations about medicines. Based on the recommendations of the National Overprescribing Review (NOR) published in September 2021, the programme aims to achieve the following outcomes: A national network of Polypharmacy Communities of Practice, all working to address the system-wide challenges of problematic polypharmacy in their geographies. Routine use of the NHSBSA Polypharmacy Prescribing Comparators to identify and prioritise patients for a shared decision-making Structured Medication Review. Increased confidence amongst the primary care prescribing workforce to safely stop medicines identified to be inappropriate or unnecessary. A change in patient expectations – to anticipate having a shared decision-making conversation about their medicines regularly, especially as they get older. A contribution to the evidence base around how to help patients to feel more empowered to open up about their medicines issues. A contribution to the evidence base around how to tackle problematic polypharmacy.
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Content ArticleRepeated culture of safety surveys of the nursing staff at Children’s Hospital of Philadelphia’s main campus demonstrated lagging scores in the domain of nonpunitive responses to error. The hospital had tried for many years to address the problem using a variety of strategies, including small group training sessions on just culture for staff and leaders, but had met with limited success. Finally, in 2015, it committed to trying something genuinely different—even perhaps disruptive—that might actually shift the stagnant metrics. Their novel, multifaceted programme, implemented over a two-year period, yielded a 13% increase in staff rating scores that the hospital has been able to sustain over the subsequent two-year period. The design and rollout of our program was neither simple nor smooth, but valuable lessons were learned about realistic, operational implementation of principles of psychological safety in a large and complex clinical organisation. In this paper, Neiswender et al. describe the programme and the lessons learned in the journey from idea inception to post-implementation.
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Event
Just Culture and incident investigation
Patient Safety Learning posted an event in Community Calendar
untilThis virtual seminar from the Clinical Human Factors Group will be looking at Just Culture and incident investigation and will feature two of the authors, Jan Davies and Carmella Steinke, of the new book 'Fatal Solution' , a book which describes "how a healthcare system used tragedy to transform itself and redefine Just Culture". In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture." To accompany this story Ken Catchpole, Professor of Human Factors at Medical University of South Carolina will discuss a variety of enablers and barriers to learning from clinical safety incidents, based on his perspective within the US health system. This will illustrate the format of incident analysis and response at MUSC; legal and regulatory issues; and the role and impact of human factors and systems engineering. He will also comment on the recent RaDonda Vaught case, and what that tells us about how far we still have to go. Jane O’Hara, Professor of Healthcare Quality and Safety in Leeds will adds a UK perspective to this worldwide issue, together with a session focusing on the view from a pharmacy perspective. Register- Posted
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Content ArticleA blog from the Patients Association for World Patient Safety Day on why patient partnership is key to the safe prescribing, supply and taking of medicines. "Being prescribed medication is one of the most common interactions between patient and healthcare professional: this World Patient Safety, let’s ensure all medicine prescribed today is done so following a discussion of its benefits and risks and with the patient’s full participation."
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Content ArticlePatients, families, and care providers affected by patient safety incidents expect there will be learning and improvement so that others will not suffer. For that, countries need mature data systems and a culture of safety that includes improving by learning from reporting hazards, harm, and near misses, as well as learning from situations and organisations where safe care is delivered consistently over time, which is in most cases. In this article, Ioana Popescu discusses patient safety in Canada. While systems are in place to support incident reporting, sharing, and learning from a variety of sources, in Canada truly national incident reporting is limited to medications, adverse drug reactions, and device failures. However, there are other pan-Canadian and grassroots efforts to advance reporting and learning from patient safety incidents that are complementary.
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Content Article
In this blog, Nigel Roberts, who is a registered Allied Health Professional theatre lead at the University Hospitals of Derby and Burton (which has in excess of 50 operating theatres and performs over 50,000 procedures annually), considers the current challenges facing all operating theatre staff post pandemic. Nigel looks at how human factors may influence the delivery of the surgical safety checklist, and discusses whether Local Safety Standards for Invasive Procedures (LocSSIPs) are making a difference in terms of the number of intra-operative Never Events being reported.- Posted
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Content ArticleIn this blog, Ian Lavery, Senior Investigation Science Educator at the Healthcare Safety Investigation Branch (HSIB) summarises a presentation given to HSIB staff by healthcare improvement expert Professor Mary Dixon-Woods. The presentation highlighted that a recommendation alone could fall short of the intended impact on the healthcare system. It looked at creating recommendations to respond to real world working, the importance of involving people most affected by patient safety incidents and why it's vital to look at when things go right.
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Content ArticlePatient safety culture is a vital component in ensuring high-quality and safe patient care. This cross-sectional study aimed to assess doctors’ and nurses’ perceptions of patient safety culture in five public general hospitals in Hanoi, Vietnam. The study found that the mean scores among nurses were significantly higher than that among physicians for several categories: supervisor/manager expectations staffing management support for patient safety teamwork across units handoffs and transitions Nurses reported significantly higher patient grades than physicians (75% vs 67.1%) and around two-thirds of physicians and nurses reported no event in the past 12 months (62.8 and 71.7% respectively). The authors recommend that hospitals develop and implement intervention programs to improve patient safety, including around teamwork and communication, encouraging staff to notify incidents and avoiding punitive responses.
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Content Article
Advancing Quality Alliance: Safety Culture Survey
Patient Safety Learning posted an article in Culture
This programme from the Advancing Quality Alliance (Aqua) provides participants with the tools, skills and knowledge to oversee the successful implementation of a safety culture survey in organisations. Participants of this programme will develop a working knowledge of safety culture theory and the Agency for Healthcare Research and Quality (AHRQ) safety culture survey alongside the support that Aqua provides to enable deployment and analysis of the survey. This programme links directly to Aqua’ safety offers, including Psychological Safety, Human Factors and Improvement Practitioner programmes. -
Content ArticleThis article in the journal Implementation Science aims to offer a system for classifying implementation strategies. The article recommends that authors not only name and define their implementation strategies, but also specify who enacted the strategy, and the level and determinants that were targeted.
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Content ArticleThis cross-sectional study in BMJ Quality & Safety aimed to assess patient comfort in speaking up about problems during hospitalisation, and to identify patients at increased risk of having a problem and not feeling comfortable speaking up. The authors assessed the responses of 10,212 patients at eight hospitals in Maryland and Washington to the question, "How often did you feel comfortable speaking up if you had any problems in your care?" The study found that 48.6% of respondents indicated that they had experienced a problem during hospitalisation. Of these, 1,514 (30.5%) did not always feel comfortable speaking up. The authors concluded that creating conditions for patients to be comfortable speaking up may result in service recovery opportunities and improved patient experience.
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Content ArticleSerious case reviews from the past twenty years have repeatedly highlighted the absence of professional curiosity as a core failing in the actions of health and social care professionals. However, 'professional curiosity' as a term is still not commonly used amongst healthcare professionals and there is no shared understanding of its meaning. This paper published by Diabetes on the Net, critically reviews current research surrounding professional curiosity and discusses the main themes. explores how inter-agency working can promote professional curiosity by supporting healthcare professionals to overcome the complex barriers that may arise during safeguarding cases. It discusses the role of Children and Young People’s diabetes clinics as an ideal platform for utilising the benefits of professional curiosity.
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Content ArticleThis article describes perceptions of the culture of safety in paediatric primary care in the US, and evaluates whether organisational factors and staff roles are associated with these perceptions. The authors found that perceptions of the culture of safety and quality in paediatric primary care practices were generally positive, but differences in perceptions did exist based on staff role.
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Content ArticlePresentation from Professor Mark Brinell, Vice Chair and Global Healthcare Expert at KMPG, on lessons we can learn from integrated care systems across the globe.
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