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Showing results for tags 'Safety culture'.
Found 534 results
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Content Article
Civility Saves Lives
PatientSafetyLearning Team posted an article in Good practice
Civility Saves Lives are a collective voice for the importance of respect, professional courtesy and valuing each other. They aim to raise awareness of the negative impact that rudeness (incivility) can have in healthcare, so that we can understand the impact of our behaviours. Their goal is to disseminate the science of the impact of incivility in healthcare. They also strive to research and collaborate on data about the impact of incivility. -
Content ArticleThis evidence scan provides a brief overview of some of the tools available to measure safety culture and climate in healthcare. Safety culture refers to the way patient safety is thought about and implemented within an organisation and the structures and processes in place to support this. Safety climate is a subset of broader culture and refers to staff attitudes about patient safety within the organisation. Measuring safety culture or climate is important because the culture of an organisation and the attitudes of teams have been found to influence patient safety outcomes and these measures can be used to monitor change over time. It may be easier to measure safety climate than safety culture.
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Content Article
No blame culture, a blog by Joanne Hughes
PatientSafetyLearning Team posted an article in Bullying and fear
In this powerful blog, based on her personal experience of losing a child, Joanne Hughes argues you can (and should) identify and blame the error, the 'act or omission’ for the harm, but very often it is not appropriate or fair to blame the 'person' who carried out that act. Avoidably grieving parents, she highlights, do need to know 'what' is to blame and 'why' it occurred. -
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Freedom to Speak Up Guardian survey 2019
Patient Safety Learning posted an article in Speak Up Guardians
A new report published by the National Guardian’s Office reveals that the perception of the speaking up culture in health is improving. An annual survey, conducted by the National Guardian’s Office, asked Freedom to Speak Up Guardians, and those in a supporting role, about how speaking up is being implemented in their organisation. The results reveal details about the network’s demographics and their perceptions of the impact of their role. This infographic highlights some of the findings. -
Content ArticleThis joint report by the Prison Reform Trust (PRT), INQUEST and Pact (the Prison Advice and Care Trust) reveals that most prisons in England and Wales are failing in their duty to ensure that emergency phone lines are in place for families to share urgent concerns about self-harm and suicide risks of relatives in prison. This is in serious breach of government policy that families should be able to share concerns ‘without delay’.
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Content Article
CQC Podcast: Give feedback on care (14 January 2020)
Claire Cox posted an article in Care Quality Commission (CQC)
Episode 1 in this podcast series from the Care Quality Commission talks about the work they have been doing to collect people's experiences of care through the development of their 'Give Feedback on Care' service, their public campaigns work and the work of their national contact centre. -
Content ArticleThe appointment of a Freedom to Speak Up (FTSU) Guardian is a requirement of the NHS Standard Contract in England. The National Guardian’s Office (NGO) provides leadership, support and guidance to FTSU Guardians. Guidance on recording data was originally issued in January 2017 and guardians in trusts and foundation trusts have been asked to provide quarterly reports on the number of cases they have received since April 2017. These quarterly reports have been published on the NGO’s webpages. This end of year report represents a summary and analysis of the second year’s return and compares across the two years for which data is available.
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Content Article
The real second victims
Patient Safety Learning posted an article in Second victim
In many professions, specific terms – both old and new – are often established and accepted unquestioningly, from the inside. In some cases, such terms may create and perpetuate inequity and injustice, even when introduced with good intentions. One example is the term ‘second victim’. The term ‘second victim’ was coined by Albert W Wu in his paper ‘Medical error: the second victim’. Wu wrote the following: “although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victims”. In his blog, Stephen Shorrick discusses the term second victim, what patients and families think of this term, and proposes that healthcare professionals are perhaps the 'third victims'. -
Content Article
Second victim support for managers
Patient Safety Learning posted an article in Second victim
This second victim support website was designed as a resource for clinicians who are involved in a patient safety incident, their colleagues and the organisations they work for. It has been developed by a team from the Yorkshire Quality and Safety Research Group and the Improvement Academy. It is supported by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre. -
Content ArticleThis presentation, delivered by Margaret Murphy, Lead Advisor for the World Health Organization, took place at the Patient Safety Learning conference. In this short video, Margaret argues that the hear of the matter is in the patient'd and families experiences of care and how this, alongside true engagement, can be used to drive improvement.
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Content ArticleAll healthcare professionals have a duty of candour – a professional responsibility to be honest with patients when things go wrong. This is described in 'The professional duty of candour', which introduces this guidance and forms part of a joint statement from eight regulators of healthcare professionals in the UK. This guidance from the Nursing and Midwifery Council complements the joint statement from the healthcare regulators and gives more information about how to follow the duty of candour principles.
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Content ArticlePatients have different concerns from clinicians when asked about problems with their care, and may identify preventable safety issues. When trained volunteers surveyed 2,471 patients from three NHS Trusts in England, 23% of patients identified concerns about their care. The biggest category of concerns related to communication, with staffing issues and ward environment the next most common and safety issues. Although the majority of safety issues were categorised as negligible or minor, they were also seen as definitely or probably preventable. Patient-reported concerns identified new areas which may not have been picked up by staff, such as fear of other patients or delays in procedures. This is one of the largest studies to look at patient safety concerns from the patient perspective. This study suggests that inpatient surveys can identify patient safety issues and that collecting this data could help trusts identify areas where patient experience could be improved. However, for the data to be useful, it needs to be routinely collected, reviewed and acted upon, which may be difficult to implement.
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Content ArticleWhen the Harvard Business Review (HBR) asked Robert Sutton for suggestions for its annual list of Breakthrough Ideas, he told them that the best business practice he knew of was 'the no asshole rule'. Sutton's piece became one of the most popular articles ever to appear in the HBR. Spurred on by the fear and despair that people expressed and the tricks they used to survive with dignity, Sutton was persuaded to write this book. He believes passionately that civilised workplaces are not a naive dream, that they do exist, do bolster performance and that widespread contempt can be erased and replaced with mutual respect when a team or organisation is managed right. There is a huge temptation by executives and those in positions of authority to overlook this trait especially when exhibited by so-called producers, but Sutton shows how overall productivity suffers when the workplace is subjected to this kind of stress.
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Content ArticleIncivility chips away at people, organisations, and our economy. Slights, insensitivities, and rude behaviors can cut deeply. Moreover, incivility hijacks focus. Even if people want to perform well, they can't. Customers too are less likely to buy from a company with an employee who is perceived as rude. In this book, Christine Porath shows how people can enhance their influence and effectiveness with civility. Combining scientific research with fascinating evidence from popular culture and fields such as neuroscience, medicine, and psychology, this book reminds managers and employers what they can do right now to improve the quality of their workplaces.
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Content ArticleAs I mentioned in my previous blog (part 3), the number of staff using the SISOS calm zone as a safe space to take time out was surprising because of the sheer volume and also the average time it was used for (15 minutes). Certain factors contribute to the success of a safe space: management buy-in, location and, to a degree, ambiance. At Chase Farm Hospital, we have been fully supported locally and at a trust level. However, in any organisation there will always be people who are averse to change. In this blog I will share with you some of the negative experiences I encountered, because anyone thinking of setting up a similar initiative needs to be aware that it is not always plain sailing and unfortunately not everyone sees the need to support staff. I will also share with you how SISOS is evolving to meet our staff's needs.
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Content ArticleSam Morrish, a three-year-old boy, died from sepsis on 23 December 2010. An investigation, undertaken by the Parliamentary and Health Service Ombudsmen (PSHO) in 2014, found that had Sam received appropriate care and treatment, he would have survived. Yet, previous NHS investigations failed to uncover that his death was avoidable. So the family asked PSHO to undertake a second investigation to find out why the NHS was unable to give them the answers they deserved after the tragic death of their son.
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Content Article
Miles Sibley: Changing the culture of learning from deaths
Patient Safety Learning posted an article in Culture
In this BMJ Opinion article, Miles Sibley, Director for the Patient Experience Library, reflects on why there is still a failure to listen to patients and bereaved families when things go wrong. Instead we find that over and over again, when patients die avoidable deaths, their shocked and grieving relatives are locked out of investigations, refused access to information, and denied justice. -
Content Article
Patient safety in oral surgery
PatientSafetyLearning Team posted an article in Dentist
This article from the British Association of Oral Surgeons (BAOS) highlights that these clinicians perform a high volume of multi-site complex procedures, on anxious patients who are frequently conscious, that have the potential for error to occur. -
Content ArticleSeveral organisations, researchers and clinicians have discussed the need for a patient safety culture in dentistry. Strategies are available to help improve patient safety in healthcare and deserve further consideration in dentistry. Published by the British Dentistry Journal, this article: discusses the history of patient safety initiatives in healthcare and dentistry describes strategies that can be applied to identify patient safety issues in dentistry emphasises the importance of both process and cultural factors in developing a safer healthcare environment.
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Content ArticleCommunication and care delivery is enhanced when teams work together well. TeamSTEPPS® is a US government set of teamwork tactics and tools designed to help health care professionals work together safely and effectively.
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Content Article
From Safety-I to Safety-II: A White Paper (2015)
PatientSafetyLearning Team posted an article in Organisational
This White Paper, published by the authors, helps explains the key differences between, and implications of, two ways of thinking about safety (Safety-I and Safety-II). -
Content ArticleThe current approach to patient safety, labelled Safety-I, is predicated on a ‘find and fix’ model. It identifies things going wrong, after the event, and aims to stamp them out, in order to ensure that the number of errors is as low as possible. Healthcare is much more complex than such a linear model suggests. This article, published by the International Journal for Quality in Health Care, argues that we need to switch the focus to what we have come to call Safety-II, a concerted effort to enable things to go right more often. The key is to appreciate that healthcare is resilient to a large extent, and everyday performance succeeds much more often than it fails.
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Content ArticlePromoting patient and occupational safety are two key challenges for hospitals. Recent studies have shown there are key topics that are interrelated and form a critical foundation for promoting patient and occupational safety in hospitals. So far, these topics have mainly been studied independently from each other. This study did a combined assessment of hospital staffs’ perceptions of four different topics: psychosocial working conditions leadership patient safety climate occupational safety climate.
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Content Article
Human factors and ergonomics in practice (2017)
Claire Cox posted an article in Recommended books and literature
This edited book concerns the real practice of human factors and ergonomics (HF/E), conveying the perspectives and experiences of practitioners and other stakeholders in a variety of industrial sectors, organisational settings and working contexts. The book blends literature on the nature of practice with diverse and eclectic reflections from experience in a range of contexts, from healthcare to agriculture. It explores what helps and what hinders the achievement of the core goals of HF/E: improved system performance and human wellbeing. -
Content ArticleSafety has traditionally been defined as a condition where the number of adverse outcomes was as low as possible (Safety-I). From a Safety-I perspective, the purpose of safety management is to make sure that the number of accidents and incidents is kept as low as possible, or as low as is reasonably practicable. This means that safety management must start from the manifestations of the absence of safety and that - paradoxically - safety is measured by counting the number of cases where it fails rather than by the number of cases where it succeeds. This unavoidably leads to a reactive approach based on responding to what goes wrong or what is identified as a risk - as something that could go wrong. Focusing on what goes right, rather than on what goes wrong, changes the definition of safety from ‘avoiding that something goes wrong’ to ‘ensuring that everything goes right’. More precisely, Safety-II is the ability to succeed under varying conditions, so that the number of intended and acceptable outcomes is as high as possible. From a Safety-II perspective, the purpose of safety management is to ensure that as much as possible goes right, in the sense that everyday work achieves its objectives. This means that safety is managed by what it achieves (successes, things that go right), and that likewise it is measured by counting the number of cases where things go right. In order to do this, safety management cannot only be reactive, it must also be proactive. But it must be proactive with regard to how actions succeed, to everyday acceptable performance, rather than with regard to how they can fail, as traditional risk analysis does. This book analyses and explains the principles behind both approaches and uses this to consider the past and future of safety management practices. The analysis makes use of common examples and cases from domains such as aviation, nuclear power production, process management and health care. The final chapters explain the theoretical and practical consequences of the new perspective on the level of day-to-day operations as well as on the level of strategic management (safety culture). Safety-I and Safety-II is written for all professionals responsible for their organisation's safety, from strategic planning on the executive level to day-to-day operations in the field. It presents the detailed and tested arguments for a transformation from protective to productive safety management.
