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Showing results for tags 'Safety culture'.
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Content ArticleMaternity services shouldn’t be waiting for whistle-blowers or inquiries to alert them to problems, says Dr Mark Ratnarajah, a practising paediatrician and managing director of C2-Ai. Instead systematic transdisciplinary reviews and real-time data should support a culture of shared learning, that helps ensure patient safety is everybody’s responsibility.
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Content Article
Questions & answers: World Hand Hygiene Day 2022
Patient Safety Learning posted an article in WHO
The 5 May is World Hand Hygiene Day. This year's theme is focused on recognising that we can add to a facility's climate or culture of safety and quality through cleaning our hands but also that a strong quality and safety culture will encourage people to clean hands at the right times and with the right products. See the World Health Organization's questions and answers about World Hand Hygiene Day. -
Event
Webinar: World Hand Hygiene Day 2022
Patient Safety Learning posted an event in Community Calendar
When people seek healthcare, they are hoping to get better. Too often, however, they end up getting a new, avoidable infection – which is often resistant to antimicrobials and can sometimes even be fatal. When a health facility’s “quality and safety climate or culture” values hand hygiene and infection prevention and control (IPC), this results in both patients and health workers feeling protected and cared for. That is why the World Hand Hygiene Day (WHHD) theme for 2022 is a “health care quality and safety climate or culture” that values hand hygiene and IPC, and the slogan is “Unite for safety: clean your hands”. This webinar will bring together experts from WHO and from academic institutions and leaders from the field to discuss how a strong institutional quality and safety climate or culture that values hand hygiene and IPC is a critical element of effective strategies to reduce the spread of infection and antimicrobial resistance. New evidence on this as well as priorities for research in this area identified by WHO will be presented. With the help of a facilitator, participants will have the unique opportunity to dialogue with the expert panel and bring their experiences. The webinar will also be the exceptional moment for the launch of the first WHO global report on IPC. Now is the time to unite by talking about and working together on an institutional safety climate that believes in hand hygiene for IPC and high-quality, safe care. Objectives To overview the new WHO hand hygiene research agenda and evidence on the role of a health care quality and safety climate or culture for hand hygiene improvement. To describe a range of experiences regarding the evidence for and efforts to support a health care quality culture and safety climate through clean hands and IPC programmes of work. To launch the first WHO global report on IPC. Register -
Content ArticlePositive defensive medicine describes an approach to healthcare that involves excessive testing, over-diagnosing and overtreatment. Negative defensive medicine, on the contrary, describes an approach where doctors avoid, refer or transfer high risk patients. This article in Patient Safety in Surgery examines how both defensive medicine approaches can contribute to medical errors.
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Content ArticleThe Safety Culture Programme for Maternity & Neonatal Board Safety Champions was commissioned by NHSE/I Women’s Health Policy team. The programme was co-designed with stakeholders including Board Safety Champions, Leaders from the Maternity and Neonatal system and Maternity Voices Partnership through March 2021. The programme is underpinned by the NHSE/I framework developed by the Maternity Transformation Programme Board. The aim of the framework and the programme (concluded on 25 March 2022) is to create the conditions for a culture of safety and continuous improvement across perinatal services to improve the quality, safety and experience of care. View the presentation slides from the recent Aqua event and an overview of the HSIB Investigation Programmes highlighting the differences between the National Investigations Programme and the Maternity Investigations Programme.
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Content ArticleMedication safety events with the potential for patient harm do occur in healthcare settings. Pharmacists are regularly tasked with utilizing their medication knowledge to optimize the medication-use process and reduce the likelihood of error. To prepare for these responsibilities in professional practice, it is important to introduce patient safety principles during educational experiences. The Accreditation Council for Pharmacy Education (ACPE) and the American Society of Health-System Pharmacists (ASHP) have set forth accreditation standards focused on the management of medication-use processes to ensure these competencies during pharmacy didactic learning and postgraduate training. The experience described here provides perspective on educational and experiential opportunities across the continuum of pharmacy education, with a focus on a relationship between a college of pharmacy and healthcare system. Various activities, including discussions, medication event reviews, audits, and continuous quality improvement efforts, have provided the experiences to achieve standards for these pharmacy learners. These activities support a culture of safety from early training.
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Content ArticleThis customisable, educational toolkit published by the Agency for Healthcare Research and Quality (AHRQ) aims to help ICUs reduce rates of central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). The materials can be used to assess current safety practice, implement new approaches and overcome particular challenges related to CLABSI and CAUTI in ICUs.
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Content ArticleThis article in the journal Archives of Disease in Childhood examines patient safety theories and suggests principles to tackle safety challenges specific to paediatric care. The authors provide an overview of the evolution of patient safety theories and tools such as huddles and electronic prescribing. They look at the example of Paediatric Early Warning Systems (PEWS), highlighting that the organisational context and culture in which PEWS is used will dramatically affect its effectiveness as a tool. They conclude that approaches to patient safety must see it as a complex interconnected whole, rooted in the culture and environment in which safety interventions act. They also argue that paediatricians must take a lead in improving the safety of the care they deliver on a systems basis.
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Content ArticlePublic satisfaction with the NHS is currently at a 25-year low, and lack of effective communication and engagement with patients has contributed to this dissatisfaction. In this blog, Lucy Watson, Chair, and Rachel Power, Chief Executive of The Patients Association, reflect on the findings of the Ockenden Report and the implications for patient trust in the NHS. They highlight the immense damage to trust caused by the combination of the hospital's substandard clinical care, lack of compassion, tendency to blame mothers and unwillingness to respond to concerns. The authors argue that listening to and better engaging with patients is essential to create the culture change the NHS needs to rebuild public trust and improve safety. They call for honest and transparency about how the NHS is coping, and for more action to tackle low staff morale.
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Content ArticleThis report published by the National Guardian’s Office shows the experience of Freedom to Speak Up Guardians amid the continued pressure of the pandemic on the healthcare sector. Although the majority of guardians who responded to the survey were positive about the culture of their organisation, the results highlight a decline in factors that make it easy for staff to speak up, including support from leadership.
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Content Article
How are Trusts measuring safety culture? A blog from Annie Hunningher
Annie Hunningher posted an article in Culture
Annie Hunningher highlights the difficulties in measuring an organisation's safety culture and the lack of validated measurement tools available.- Posted
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Content Article
NHS Staff Survey Results 2021 (30 March 2022)
Patient-Safety-Learning posted an article in Culture
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. 648,594 staff responded to the survey this year. The full results of the 2021 NHS Staff Survey are published on the NHS Staff Survey website. -
Content Article
Civility Saves Lives Infographics
Patient Safety Learning posted an article in Good practice
Civility Saves Lives have created a number of infographic each with a key message of civility. A selection are shown below and more can be found through the link at the bottom of the page. -
EventThis one day masterclass will focus on improving Patient Safety through enhancing psychological safety and safety culture. It looks at effective ways to encourage health professionals to routinely embed high-quality clinical evidence into their everyday work. We will explore the characteristics of relatively successful behaviour change interventions. All Clinical Staff and Team Leads should attend. Key learning objectives: psychological safety safety culture behaviour human factors how to improve safety reporting. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/improving-psychological-safety-patient-safety or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code
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Content ArticleThe experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis within the team. This study in the Journal of Patient Safety aimed to establish whether patient safety culture, as measured by the Hospital Survey on Patient Safety Culture (HSOPS), differed regarding care provider involvement in EFC activities. The authors found that participation in EFC activities was associated with higher patient safety culture scores, suggesting that root cause analysis in the team’s routine may improve patient safety culture.
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Content ArticleIn this blog, Jessica Behrhorst, Senior Director for Patient Safety at the Institute for Healthcare Improvement (IHI), discusses challenges staff face in creating a safety culture, such as fear of negative consequences and thinking they will not be taken seriously. She highlights the importance of acknowledging these fears and building positive group norms in order to engage staff. She also highlights the role of root cause analysis in addressing fears about speaking up.
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EventuntilEast Midlands and West Midlands Patient Safety Collaboratives will be hosting a webinar on appreciative inquiry (AI). Hosted by Appreciating People, it will focus on ‘what works’ and the existing strengths and assets of people, team and organisations. The pandemic and current working challenges has shown how resilient and creative the maternity and neonatal workforce has been, so this workshop aims to support you to build upon your current knowledge and experiences. The webinar will share tools to focus on levering and amplifying strengths, and there will be time for reflective conversation with colleagues. AI helps build psychological safety and is extensively used by many NHS trusts who are part of Learning From Excellence. Register for the webinar
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Content ArticlePatients falling (falling, slipping) is considered one of the most important patient safety risks in the elderly, in health institutions (hospitals, health centres..., etc.) in particular, and more generally in daily life activities at home, out shopping, etc. In this article I call for a cultural transformation for avoiding falls: from a culture of patient safety that focuses on falls within health facilities to a wider societal culture that must be adhered to by all members of society to prevent the risks of falling in the elderly and other groups at high-risk (including those with specific diseases, disabilities due to congenital causes, accidents...).
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Content Article
This is the third in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Deinniol tells us about how his role at the Healthcare Safety Investigation Branch (HSIB) helps make healthcare services in the UK safer for both patients and staff. He explains the importance of understanding the complexity of healthcare systems and the pressures that staff within the NHS face. He highlights the need build trust with patients, staff and other stakeholders to find ways forward in improving patient safety. -
Content ArticleMeasures of patient safety culture from the perspective of health workers can be used – along with patient-reported experiences of safety, traditional patient safety indicators (see indicator “Safe acute care – surgical complications and obstetric trauma”) and health outcome indicators (see, for example, indicator “Mortality following acute myocardial infarction”) – to give a holistic perspective of the state of safety in health systems.
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Content ArticleThis article in BMJ Quality and Safety looks back at how the patient safety movement has developed over the last two decades. It argues that although the aim of the movement is to change systems, in reality this has not happened on a wide scale. The authors suggest that if we are to make quantitative improvements to patient safety, the next stage of the patient safety movement needs to prioritise substantive, system-wide change.
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Content ArticleThis briefing by NHS Supply Chain looks at shared learning on patient safety, and how collaborative working is enabling better assurance and safety for healthcare products and services. The briefing covers these topics: The role of NHS Supply Chain in patient safety Safety specifications for safer products System-level join up Human factors and just culture Case studies Overview of system partners Conclusion
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Content ArticleThis study in Risk Management and Healthcare Policy aimed to explore healthcare workers’ perceptions of patient safety culture at primary healthcare centres in the Eastern Province of Saudi Arabia, and the factors that influence them. It also aimed to identify the challenges of adopting patient safety culture in these centres. The study findings highlight a number of areas for improvement, particularly in relation to event reporting, non-punitive responses, and openness in communication. The authors highlight that error reporting should not just be considered a means of learning from mistakes, but should also be considered the first step towards preventing injury and improving patient safety. They highlight the need to eliminate three crucial elements associated with errors - blame, fear, and silence - in order to build a safety culture.
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EventThis one day masterclass will focus on how to use behavioural insights and Nudge Theory to look at patient safety and safety culture. Nudge-type interventions have the potential for changing behaviours. We will look at examples of Nudge Theory use in healthcare and external organisations and how we can use these to improve patient safety and also to reduce inefficiency and waste. We will look at the type of interventions suitable for nudges and how to develop them. Key learning objectives: Behavioural insights Nudge Theory Use of nudge theory to improve patient safety Developing nudges Opportunities for Nudge-type interventions. Register
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Content Article
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This is the first in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Josie tells us about the nursing error that first sparked her interest in patient safety, how a just culture helps healthcare workers and systems learn from their mistakes, and how her love of skiing has inspired her to think differently about risk in healthcare.
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