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Showing results for tags 'Safety culture'.
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Content ArticleHealth systems currently present a great degree of complexity, which provides risks to patients related to healthcare, and the possibility of incidents with or without harm. Patient safety culture highlights the need to investigate, analyse, and mitigate incidents to reduce risks to the patient. Medication errors have a high potential to do harm in paediatric hospital routines and most of them are preventable. The objective of this study was to describe a severe drug-related adverse event and present the root cause analysis and implemented improvements.
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Content Article
Research shows that poor handover in hospitals puts patients at risk of severe harm
Anonymous posted an article in Handover
Research undertaken by digital health platform, CAREFUL shows that handover in hospitals is the cause of frequent and severe harm to patients. -
Content ArticlePatient safety culture is the foundation of patient safety and refers to a healthcare organisation’s shared values, norms and beliefs that influence staff’s behaviour and actions. This study in BMJ Open Quality aimed to assess nurses’ reporting on the predictors and outcomes of patient safety culture and the differences between patient safety grades and the number of events reported. It aimed to fill a gap in research by looking at patient safety culture in terms of both predictors and outcomes. The author developed a cross-sectional comparative research design and recruited 300 registered nurses to take part in a survey on patient safety culture. The author found that nurses generally perceived patient safety culture as 'moderate', and identified areas that should be prioritised to improve patient safety culture. They concluded that assessing patient safety culture is the first step in improving hospitals’ overall performance and quality of services, and that improving patient safety practices is essential to improving culture and clinical outcomes.
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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. Annie talks to us about her work training teams in safety behaviours, why productivity and safety must go hand-in-hand, and how working on patient safety is like running a marathon. -
Content ArticleThe Ockenden review into the failings in maternity care at Shrewsbury and Telford Hospital NHS Trust in the UK makes for sobering reading. The review focuses predominantly on the period from 2000 to 2019 and estimates that there were significant or major concerns in the care of nine women and more than 200 babies who died while receiving care at the Trust. Many more women and babies suffered serious injuries. It was clear that the Shrewsbury and Telford Hospital NHS Trust did not investigate, learn, change, or listen to families when adverse events occurred. The conclusions of the Ockenden review make it clear that safe staffing levels, a well trained workforce, an ability to learn from incidents, and a willingness and ability to listen to families are all crucial for safe maternity care.
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Content Article
In this blog, student midwife Sophie Dorman describes some of the issues that have led to a chronic shortage of midwives, including a culture of fear, poor pay and conditions and a lack of basic facilities for maternity staff. She highlights the impact this is having on the safety of maternity services and argues that valuing and looking after midwives will make pregnancy and childbirth safer and better for everyone. -
Content Article
In this blog, Patient Safety Learning reflects on a recent letter by Keith Conradi to the Secretary of State for Health and Social Care, highlighting concerns about a lack of interest and attention in the activities of the Healthcare Safety Investigation Branch (HSIB) at the highest levels of the Department of Health and Social Care (DHSC) and NHS England.- Posted
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Content ArticleOn his last day in office as Chief Investigator at the Healthcare Safety Investigation Branch (HSIB), Keith Conradi sent this letter to the Secretary of State for Health and Social Care, outlining his concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB. In his letter, Keith highlights a lack of interest in HSIB investigations and activity from leaders in both NHS England and DHSC, and describes how this attitude permeates both organisations. He also draws attention to a lack of priority and support for patient safety at a structural level, and calls on government and healthcare leaders to take a new approach and introduce a regulated safety management system with appropriate accountability. Patient Safety Learning has written a blog reflecting on Keith Conradi's letter, highlighting the ways in which his concerns align with those consistently raised by Patient Safety Learning.
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Content ArticleIn this blog, nurse Carol Menashy describes her experience making an error in theatre fifteen years ago, and the personal blame she faced in the way the incident was dealt with at the time. She talks about how a SEIPS (Systems Engineering Initiative for Patient Safety) framework can transform how adverse incidents are dealt with, allowing healthcare teams to learn together and use incidents to help make positive changes towards patient safety. She describes the progress that has been made towards organisational accountability and systems thinking over the past fifteen years, and talks about the importance of staff support to allow for healing from adverse events.
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Content ArticleHealthcare is traditionally a hierarchical industry. This structure can foster a culture of division amongst staff that is sometimes made worse by significant differences in background and training. However, in order to make sure care is safe and of a high quality, healthcare teams must develop good teamwork and communication. This is only possible if every member of the team feels respected and is free to speak up when they think something is wrong. In this podcast, host David Feldman speaks to Michael Brodman, Professor and Chair Emeritus in the Department of Obstetrics, Gynecology, and Reproductive Science at the Icahn School of Medicine at Mount Sinai in the US. They discuss how mutual respect is essential for any institution developing a culture of safety and how the problems presented by medical hierarchy can be overcome.
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Content ArticleThe COVID-19 pandemic has made it more difficult to maintain high quality in medical education. As online formats are often considered unsuitable, interactive workshops and seminars have particularly often been postponed or cancelled. To meet the challenge, Angelina Müller and her colleagues converted an existing interactive undergraduate elective on safety culture into an online event. In this article, they describe the conceptualisation and evaluation of the elective.
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Content ArticleThe emotion of the team is a sum-total of emotions and feelings that members of the team experience. Left unnoticed, unexpressed, and unattended, these emotions can grow toxic to harm relationships or grossly undermine team’s potential. Leaders have a choice of either noticing those emotions intentionally and intervening constructively when needed or just ignore the emotions to focus only on the outcomes and the process. Tuning into team emotions, fostering productive relationships, building trust, and a conducive environment within the team is the constant work of leadership.
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Content ArticleThe NHS in England has introduced a range of policy measures aimed at fostering greater openness, transparency and candour about quality and safety. This study looks at the implementation of these policies within NHS organisations, with the aim of identifying key implications for policy and practice.
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Content ArticleOver the past few years, concerns have been raised about the level of funding and intervention regulators have received from the pharmaceutical industry. In this article for The BMJ, investigative journalist Maryanne Demasi examines whether regulators of medical devices and medications have enough independence from the companies they are meant to regulate. She asked six of the world's biggest regulators about their funding and transparency and found that industry money permeates the world's leading regulators. This casts doubt on their ability to provide effective regulation, especially in the wake of a string of drug and device scandals.
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Event
Creating safe systems
Patient Safety Learning posted an event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on risk and behaviour to improve patient safety. Key learning objectives: evaluating risk using mapping techniques safety interventions behaviour assessing safety culture The course is facilitated by Perbinder Grewal, a General & Vascular Surgeon, Human Factors & Patient Safety Trainer, and Emotional Intelligence Practitioner; leads on medical education both locally and nationally; Member of the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh; formerly lead for e-learning for healthcare for the Royal College of Surgeons of England; experienced trainer and coach who uses new insights to develop patient safety, staff engagement and psychological safety; has Postgraduate Certificates in Leadership and Coaching. Register -
Content ArticleThis improvement tool is designed to help NHS organisations identify strengths their leadership team and organisation, and any gaps that need work, in seeking to create an environment where people feel safe to speak up with confidence. It should be used alongside Freedom to speak up: A guide for leaders in the NHS and organisations delivering NHS services, which provides full information about the areas addressed in the statements, as well as recommendations for further reading.
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Content ArticleThe Safety culture programme group (SCPG) was a virtual task and finish group established in July 2021 for six sessions to provide recommendations to support and enable organisations to improve their safety culture through embedding a continuous cycle of understanding the issue, developing a plan, delivering the plan and evaluating the outcome with an underpinning foundation of inequalities reduction. This report contains an overview of the discussions undertaken by the Safety culture programme group (SCPG) in 2021. It also includes their recommendations so that safety culture continues to be developed as one of the foundations that underpins the NHS patient safety strategy.
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News ArticleThere’s little question that US hospitals—up against COVID, patient surges, and labor and supply shortages—have become less safe for patients during the pandemic, as preventable events and complications have become more common. Leaders with the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) said as much, earlier this year, in an article for the New England Journal of Medicine: “Many indicators make it clear that health care safety has declined,” they wrote, noting, “the fact that the pandemic degraded patient safety so quickly and severely suggests that our health care system lacks a sufficiently resilient safety culture and infrastructure.” Despite such frank assessments, CMS is now at odds with public safety advocates about whether to make some of the hospital-specific data behind those trends publicly available. Read full story (paywalled) Source: Fortune, 14 June 2022
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Content ArticleThis article in the Journal of Interprofessional Care highlights the challenges experienced by programme leaders and healthcare professionals as they work to improve patient safety. It discusses the complexities of translating organisation-wide speaking-up policies to local practices and settings.
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Content ArticleKrista Haugen is National Director of Patient Safety for US-based emergency and patient relocation services provider Global Medical Response. In this interview, she describes how her 25-year career as an emergency medicine nurse has influenced her approach to safety and patient care. She discusses her personal experience of being involved in an accident as an air-ambulance flight nurse, and how this caused her to look at safety and risk management from a systems perspective, focussing on building a just culture where safety is optimised through organisational reflection and learning.
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Content Article
Safety Chats: Part 2 – Safety as measured
Gina Winter-Bates posted an article in Good practice
In a series of blogs, Gina Winter-Bates, Associate Nurse Director Quality and Safety at Solent NHS Trust, shares her experience of implementing Safety Chats. In her first blog, Gina explained what motivated her to introduce Safety Chats into her Trust. In part 2, Gina reflects on how we know we are safe and the safety measures her Trust has put in place. -
Content Article
Leading a culture of safety: A Blueprint for success (2017)
Patient Safety Learning posted an article in Exec teams
Patient safety experts and researchers have increasingly pointed to the role of organizational culture in the success of patient and workforce safety initiatives. Yet, creating a culture of safety in health care settings has proven to be a challenging endeavour, and there is a lack of clear actions for organisational leaders to take in developing such a culture. 'Leading a Culture of Safety: A Blueprint for Success' from the Institute of Healthcare Improvement (IHI) was developed to bridge this gap in knowledge and resources by providing chief executive officers and other healthcare leaders with a useful tool for assessing and advancing their organisation’s culture of safety. This guide can be used to help determine the current state of an organisation’s journey, inform dialogue with the board and leadership team, and help leaders set priorities. -
Content ArticleOne box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable – does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? 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.
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Content ArticleThis study in the journal Health and Social Care Delivery Research mapped interventions aimed at reducing restrictive practices in children and young people’s institutional settings around the world. It also assessed which process elements led promising behaviour change techniques, and compared the results with a companion review of adult psychiatric inpatient settings. In the first evidence review of its kind, the authors found that interventions tend to be complex, reporting is inconsistent and robust evaluation data are limited. But they did find some behaviour change techniques that warrant further research. They argue that better evidence could help address the urgent need for effective strategies.
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Content Article
Safety Chats blog series: Part 1
Gina Winter-Bates posted an article in Good practice
In a series of blogs, Gina Winter-Bates, Associate Nurse Director Quality and Safety at Solent NHS Trust, shares her experience of implementing Safety Chats. In this first blog, Gina explains what motivated her to introduce Safety Chats into her Trust.
