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Showing results for tags 'Safety culture'.
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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.- Posted
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- Latent error
- Confirmation bias
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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.
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- Safety II
- Safety report
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Content ArticlePublished by the American Association of Medical Colleges (AAMC), Quality improvement and patient safety competencies across the learning continuum is designed for: faculty medical education curricula developers residents medical school administration Designated Institutional Officials (DIOs) clinical leaders at teaching hospitals and others interested in undergraduate, graduate, and continuing medical education.
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- Quality improvement
- Competency framework
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Content Article
Patient Safety, a book by Charles Vincent
Claire Cox posted an article in Recommended books and literature
When you are ready to implement measures to improve patient safety, this is the book to consult. Charles Vincent, one of the world's pioneers in patient safety, discusses each and every aspect clearly and compellingly. He reviews the evidence of risks and harms to patients, and he provides practical guidance on implementing safer practices in healthcare. The second edition puts greater emphasis on this practical side. Examples of team based initiatives show how patient safety can be improved by changing practices, both cultural and technological, throughout whole organisations. Not only does this benefit patients, it also impacts positively on healthcare delivery, with consequent savings in the economy. Patient Safety has been praised as a gateway to understanding the subject. This second edition is more than that it is a revelation of the pervading influence of healthcare errors and a guide to how these can be overcome.- Posted
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- Safety culture
- Safety process
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Content ArticleThis presentation is called Families as Partners in Achieving Safer Care and is delivered in this short film by Kath Evans, Head of Patient Experience – Maternity, Newborn, Children and Young People, NHS England.
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- Children and Young People
- Patient / family involvement
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Content ArticleAnnie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without the knee-jerk blame and shame approach of old.
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- Near miss
- Skills gap
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Content ArticleThis report summarises the themes that emerged from a restorative process to hear from New Zealand men and women affected by surgical mesh. Restorative justice approaches and practices were used to respond to harm from surgical mesh. This innovation differs to medicolegal action and inquiry approaches in other countries. A restorative approach intended to create a safe space to explore multiple experiences and perspectives of harm.
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- System safety
- Safety II
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Content ArticleThe objective of this research paper, published in the Journal of the Royal Society of Medicine, was to investigate doctors’ intentions to raise a patient safety concern by applying the socio-psychological model ‘Theory of Planned Behaviour’.
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- Safety culture
- Whistleblowing
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Content Article
Connor Sparrowhawk: The tale of laughing boy (2015)
Claire Cox posted an article in Patient stories
Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. This moving film describes what Connor was like by his friends and family and highlights the failings that caused the avoidable death of Connor.- Posted
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- Patient
- Patient death
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Content Article
Public Interest Disclosure Act 1998
PatientSafetyLearning Team posted an article in Whistle blowing
The Public Interest Disclosure Act 1998 (PIDA) protects workers by providing a remedy if they suffer a workplace reprisal for raising a concern which they believe to be genuine.- Posted
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- Accountability
- Duty of Candour
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Content Article
CQC: Report a concern
PatientSafetyLearning Team posted an article in Whistle blowing
If you're concerned about the quality of care, you can contact the Care Quality Commission (CQC). If someone is in danger you should contact the police immediately. You can call them on 03000 616161.- Posted
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- Accountability
- Duty of Candour
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Content Article
Protect: Speak up, stop harm
PatientSafetyLearning Team posted an article in Whistle blowing
Protect, formerly Public Concern at Work, aim to stop harm by encouraging safe whistleblowing. They advise people through their free, confidential advice line, train managers, senior managers and board members and support organisations to strengthen their internal whistleblowing or ‘speak up’ arrangements. They were closely involved in setting the scope and detail of the Public Interest Disclosure Act 20 years ago.- Posted
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- Duty of Candour
- Accountability
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Content Article
Speak Up
PatientSafetyLearning Team posted an article in Whistle blowing
Speaking up is the act of reporting concerns about malpractice, wrongdoing or fraud. Within the NHS and social care sector, these issues have the potential to undermine public confidence in these vital services and threaten patient safety. If you are working in this sector but don’t know what to do, or who to turn to about your concerns, Speak Up are the leading source of signposting, advice and guidance. Whether you are an employee, worker, employer or professional body/organisation, you can call their free speaking up helpline, send them an email or complete the online form safe in the knowledge everything you tell them is strictly confidential and anonymous. Speak Up offer legally compliant, unbiased support and guidance to ensure you can act in accordance with your values. This ensures you fully understand your options and legal rights specific to your employment situation. You can call the helpline on 08000 724 725.- Posted
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- Duty of Candour
- Accountability
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Content ArticleThis guidance is for all providers of health and adult social care who are registered with the Care Quality Commission (CQC) under the Health and Social Care Act 2008.
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- Accountability
- Duty of Candour
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Content ArticleMy previous blog talked about how the idea for SISOS (Safety Incident Supporting Our Staff) – an initiative to support staff involved in safety incidents – came about at Chase Farm Hospital. The SISOS team provide confidential, emotional support in a safe environment and make other support, including professional help more easily accessible. It is important to recognise that we are 'Listeners' and not professional counsellors. My second blog continues this journey.
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- Safety culture
- Team culture
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Content ArticleECRI Institute's mission is to protect patients from unsafe and ineffective medical technologies and practices. More than 5,000 healthcare institutions and systems worldwide, including four out of every five U.S. hospitals, rely on ECRI Institute to guide their operational and strategic decisions.
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- Communication
- Culture of fear
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Content ArticleMark Lomax, CEO at Patient Experience Platform, talks about the value of disruptive healthcare innovations and how to identify the 'disruption killers' and the champions within an organisation.
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- Quality improvement
- Safety culture
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Content ArticleLast year, the Canadian Patient Safety Institute (CPSI) launched a safety improvement project focused on the Measurement and Monitoring of Safety. The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety and helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.
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- Safety culture
- Transformation
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Content ArticleThere is widespread recognition that creating a safety culture supports high-quality health care. However, the complex factors affecting cultural change interventions are not well understood. This study by McKenzie et al., published in The Joint Commission Journal of Quality and Patient Safety, examines factors influencing the implementation of an intervention to promote professionalism and build a safety culture at an Australian hospital.
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- Safety culture
- Leadership
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Content ArticleIn his blog for Aish.com, Rabbi Efrem Goldberg talks about the power of a sincere apology and how this can be translated into medical care settings.
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- Safety culture
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Content ArticleSafety in aviation has often been compared with safety in healthcare. This article, published in JRSM Open, presents a comprehensive review of similarities and differences between aviation and healthcare and the application to healthcare of lessons learned in aviation.
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- Link analysis
- Assessment
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Content ArticleIn the past decade, hospitals and healthcare workers have become more familiar with medical errors and the harm they can cause. As a result, incident investigation has become a routine part of the hospital's response to an adverse event. Armed with the results of these investigations, research and quality improvement efforts are now taking on system improvements required to create a safer healthcare environment. There has also been increased attention paid to the appropriate handling of patients and families harmed by medical errors. There is developing recognition that disclosure of adverse events is necessary if hospitals are to learn from mistakes and improve patient safety outcomes. A growing number of accrediting and licensing bodies, as well as governmental entities and professional organisations, have stated the expectation that patients should be told about harmful medical errors. However, progress has been slower in translating policy into action at the level of the frontline clinician. Are these policies also beneficial to physicians and other healthcare workers, many of whom are already struggling just to get their work done? Wu and Steckelberg discuss this further in an Editorial published in BMJ Quality and Safety.
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- Patient safety incident
- Investigation
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Content ArticleAlberta Health Services (AHS) is Canada’s first and largest province-wide, fully-integrated health system, responsible for delivering health services to the more than 4.3 million people living in Alberta, as well as to some residents of Saskatchewan, B.C. and the Northwest Territories.
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- Just Culture
- Leadership
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Content Article
Caring for doctors, caring for patients (November 2019)
Claire Cox posted an article in Workforce and resources
Patient safety depends on doctors’ well-being. Medicine is a tough job, but it's made it far harder than it should be by neglecting the simple basics in caring for doctors’ well-being. The well-being of doctors is vital because there is abundant evidence that workplace stress in healthcare organisations affects quality of care for patients as well as doctors’ own health. In 2018 the General Medical Council asked Professor Michael West and Dame Denise Coia to carry out a UK-wide review into the factors which impact on the mental health and well-being of medical students and doctors. The detailed practical proposals in this report provide a road map to health service leaders faced with the challenge of developing healthy and sustainable workforces. -
Content Article
Clinician Support: Five Years of Lessons Learned
Patient Safety Learning posted an article in Second victim
The University of Missouri Health Care (MUHC), an academic healthcare system located in Columbia, Missouri, USA, deployed an evidence-based emotional support structure for second victims based on research with recovering second victims. MUHC is a six-hospital healthcare system with 52 ambulatory clinics and approximately 6,500 employees. The second victim support structure, known as the forYOU Team, was designed to increase awareness of the second victim phenomenon, “normalise” the psychological and physical impacts, provide real-time surveillance for possible second victims within clinical settings, and render immediate peer-to-peer emotional support when a potential second victim is identified. This article published in Patient Safety & Quality analyses the success of the programme.- Posted
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- Patient safety incident
- Impact anaylsis
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