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Showing results for tags 'Safety culture'.
Found 533 results
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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 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 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'The state of care in NHS acute hospitals 2014 to 2016' presents findings from the Care Quality Commission (CQC's) programme of NHS acute comprehensive inspections. The report captures what has been learned from three years’ worth of inspections. It gives a baseline on quality that is unique in the world – and also shows that it is possible, even in challenging times, to deliver the transformational change that is needed if the NHS is to continue delivering high-quality care into the future.
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EventuntilThe story of Alison Bell, and her family's uncovering of the truth about what happened to her in the care of an NHS Trust will be told by her brother Tom. He will describe the nature of the various investigations that were held into Alison's death and the role of the prevailing cultures within the public sector organisations they have dealt with; the NHS, Police, CPS and Regulatory Bodies. This true and ongoing story shines a light on the personal, emotional and financially costly impact that public sector service cultures can have on the lives of their service-users and their own bottom-line. Tom’s lived and current experience will help us to explore the implications for our own practice and the organisations we might seek to influence, manage and lead. Registration
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EventuntilThis unique 1-day distance-learning course from Medled is delivered via Zoom by our expert trainers in a format designed to maximise learning retention and application of knowledge. You'll learn to: Understand the concept of systems thinking and models of safety – looking beyond the individual and the flawed concept of ‘Human Error’. Gain an introduction to human capabilities & limitations & how those influence quality and safety of care – how humans can be heroes and hazards. Be able to unpick the nature of human fallibility and why practice does not always make perfect. Have the knowledge to proactively contribute to the safety culture in your organisation. Be able to recognise error-provoking conditions and influence your systems of work. Understand the relationship between stress and performance/risk of error. Take away a tangible model for understanding the relationship between our physiological needs and performance – do we set ourselves up to fail? Understand strategies to optimise high-performance teamworking with ad hoc teams. Evidence-based, utilising cutting edge safety & performance science this course is suitable for all Healthcare Professionals, both clinical and non-clinical; it is applicable to all departments and multi-disciplinary teams. Accredited by Chartered Institute of Ergonomics & Human Factors, you'll take part in interactive actitvities and leave with practical tools to take away. Registration
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COVID-19: Sharing the international lessons learned
Clive Flashman posted an event in Community Calendar
untilThe Royal Society of Medicine's International COVID-19 Conference brings together thought leaders from around the world to share the key clinical learnings about COVID-19.Session 1: Respiratory effects: critical care and ventilationChair: Dr Charles Powell, Janice and Coleman Rabin Professor of Medicine System Chief, Icahn School of Medicine, Mount Sinai> Professor Anita K Simonds, Consultant in Respiratory and Sleep Medicine, RBH NHS Foundation Trust> Dr Richard Oeckler, Director, Medical Intensive Care Unit, Mayo Clinic, Minnesota> Dr Eva Polverino, Pulmonologist, Vall D’Hebron BarcelonaSession 2: Cardiovascular complications and the role of thrombosisChair: Rt Hon Professor Lord Ajay Kakkar PC, Professor of Surgery, University College London> Professor Barbara Casadei, President, European Society of Cardiology> Professor K Srinath Reddy, President, Public Health Foundation of India> Professor Samuel Goldhaber, Associate Chief and Clinical Director, Division of Cardiovascular Medicine, Harvard Medical SchoolSession 3: Impacts on the brain and the nervous systemsChair: Professor Sir Simon Wessely, President, Royal Society of Medicine> Dr Hadi Manji, Consultant Neurologist and Honorary Senior Lecturer, National Hospital for Neurology> Dr Andrew Russman, Medical Director, Comprehensive Stroke Center, Cleveland Clinic> Professor Emily Holmes, Distinguished Professor, Uppsala UniversitySession 4: Looking forwardChair: Professor Roger Kirby, President-elect, Royal Society of Medicine> Dr Andrew Badley, Professor and Chair of Molecular Medicine, Chair of the Mayo Clinic COVID research task force, Mayo Clinic> Professor Robin Shattock, Professor of Mucosal Infection and Immunity, Imperial College London> Professor Sian Griffiths, Chair, Global Health Committee and Associate Non-Executive member, Board of Public Health England> Dr Monica Musenero, Assistant Commissioner, Epidemiology and Surveillance, Ministry of Health, Uganda Book here -
Content ArticlePatient safety has been considered the heart of healthcare quality. This study from Najjar et al. in Safety in Health aimed to explore relationships between patient safety culture and adverse event rates at unit levels in Palestinian hospitals, and provide insight on initiatives to improve patient safety. The study confirms the idea that a more positive patient safety culture is associated with lower adverse events in hospitals at the departmental levels in Palestine. Further analysis should include a more representative sample to examine the causal relationship between patient safety culture and adverse events incidents.
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Content ArticleIn September this year, as part of World Patient Safety Day, Patient Safety Learning asked people, via social media and the hub, to name three things staff most needed to be safe. We gathered your responses and are now pleased to present an image which shows the most common themes. According to the responses we received, the four themes that became most obvious – the four things you think staff most need to be safe – are: Compassionate leaders and role models who prioritise their staff’s wellbeing A respectful, supportive team with good communication and united by a common purpose A safe and just culture that invites staff to speak up Psychological safety, protecting staff from burnout.
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Content ArticleLarouzee and Le Coze describe the development of the “Swiss cheese model” and the main criticisms of this model and the motivation for these criticisms. The article concludes that the Swiss cheese model remains a relevant model because of its systemic foundations and its sustained use in high-risk industries and encourages safety science researchers and practitioners to continue imagining alternatives combining empirical, practical and graphical approaches.
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Vision Zero
Patient Safety Learning posted an article in Other countries and national agencies
Accidents at work and occupational diseases are neither predetermined nor unavoidable – they always have causes. By building a strong prevention culture, these causes can be eliminated and work related accidents, harm and occupational diseases be prevented. 'Vision Zero' is a transformational approach to prevention that integrates the three dimensions of safety, health and well-being at all levels of work. Safe and healthy working conditions are not only a legal and moral obligation – they also pay off economically. International research on the return on investments in prevention proves that every dollar invested in safety and health generates a potential benefit of more than two dollars in positive economic effects. Healthy working conditions contribute to healthy business. The International Social Security Association (ISSA)'s Vision Zero concept is flexible and can be adjusted to the specific safety, health or well-being priorities for prevention in any given context. Thanks to this flexibility, Vision Zero is beneficial to any workplace, enterprise or industry in all regions of the world. The Vision Zero campaign has energised companies and organisations worldwide with the ambition to strive towards a world of work without accidents and illness. Behind every organization stand extraordinarily engaged people, and on these pages we give them visibility. Vision Zero ambassadors are outstanding individuals from the world of politics, science and sports who are engaged in safety, health and wellbeing. The ISSA has developed a range of resources to support the Vision Zero Campaign and the seven golden rules of Vision Zero. -
Content ArticleAccidents at work and occupational diseases are neither determined by fate nor unavoidable – they always have causes. By building a strong prevention culture, these causes can be eliminated and work related accidents, harm and occupational diseases be prevented. 'Vision Zero' is a transformational approach to prevention that integrates the three dimensions of safety, health and well-being at all levels of work. The International Social Security Association (ISSA) Vision Zero concept is flexible and can be adjusted to the specific safety, health or well-being priorities for prevention in any given context. Thanks to this flexibility, Vision Zero is beneficial to any workplace, enterprise or industry in all regions of the world.
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Content ArticleThe NHS Patient Safety Strategy requires every Trust to have a Patient Safety Specialist: an evolving role with the purpose of ensuring that “systems thinking, human factors and just culture principles are embedded in all patient safety activity”. Patient safety is a big topic, and apart from a general sense of frustration that we don’t seem to be making any progress, there’s little agreement about what the problems are, let alone the solutions. Q member, John Tansley discusses his philosophy of patient safety through four key icons, and reflects on how this can inform and shape the evolving role of Patient Safety Specialists.
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Speak Up Month 2020
PatientSafetyLearning Team posted an article in Speak Up Guardians
Throughout October, the National Guardian, will be sharing their 'Alphabet' of Speak Up – from Anonymity to Zero Tolerance. A month to explore what 'Freedom to Speak Up' means in health.- Posted
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Rethinking Patient Safety: Maternity safety (4 October 2020)
Patient Safety Learning posted an article in Maternity
Suzette Woodward reflects on the recent reports and research into maternal safety and why we need to shift to a Safety II approach. -
Content ArticleThe Association of Anaesthetists has published two posters highlighting what to do if you see unprofessional behaviours to make hospitals safer for patients and staff.
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Content ArticleThis report tracks the progress made against the NHS Patient Safety Strategy objectives.
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The problem with policies – a blog by Lynne Williams
Lynne Williams posted an article in Improving patient safety
How can we turn the good intentions of a policy into a working model that people use? How can we ensure policies are translated into real, practical solutions? In this blog, Lynne Williams discusses why effective policy implementation is as crucial and important as the content and why we need to look at policies as a collaborative project, headed up by Governance, but written in partnership with the staff that use them to ensure we provide consistent, safe care. -
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Ehi Iden, hub topic lead for Occupational Health and Safety: OSHAfrica, reflects on a patient safety incident early on in his career. -
Content ArticleThis report from the Healthcare Safety Investigation Branch (HSIB) outlines the most important factors for supporting staff in the wake of safety incidents, against the backdrop of the COVID-19 pandemic. The report reinforces the importance of effective staff support for those suffering high levels of psychological harm, as it has a direct impact on patient care. While focusing on patient safety incidents overall, the report also provides valuable insight that could help organisations develop their own programmes of support for any situation. The report features a first-hand account from a junior doctor which charts the impact that a patient safety incident had on his life and his experiences of support. Excerpts from the story emphasise the importance of creating a ‘normalised’ culture around accessing support.
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Content ArticleThe aim of this study from Martinez et al. was to develop and test the psychometric properties of two new survey scales aiming to measure the extent to which the clinical environment supports speaking up about (a) patient safety concerns and (b) unprofessional behaviour.
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Safety climate survey – are we getting better? (12 June 2019)
Patient Safety Learning posted an article in Culture
Organisations working towards a culture of safety need a reliable measure to monitor the success of their initiatives. A Safety Climate Survey was carried out during September 2017 in the Paediatric ward at Daisy Hill Hospital, as part of the S.A.F.E. (Safety Awareness for Everyone) initiative. -
Content ArticleThe aim of this project from Hollis et al. was to improve engagement with the incident reporting process and to encourage staff to raise issues and create a proactive culture of quality improvement. This project demonstrates that a relatively simple intervention can have effect significant positive cultural change in an organisation over a small period of time. By giving frontline staff a mechanism to record issues it is possible to develop a positive culture of grass roots change. Incident reporting can act as a vehicle not only to improve patient safety but more broadly to generate ongoing ideas for quality improvement within an organisation.
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Content ArticleA blog published in Safety & Health on how you can leverage shift supervisors to ensure consistent safety knowledge among frontline workers. Although not specific to healthcare the examples can be applied to frontline healthcare workers.
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The Patient Safety Learning hub has provided the vehicle through which I’ve shared my personal journey as I sought to establish and embed a second victim support initiative at the trust where I worked until my recent retirement. Four years ago SISOS was set up to ensure that colleagues affected by safety incidents received emotional support as soon as possible. A lot of lessons have been learned along the way and positive actions taken. These are my personal thoughts.
