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Found 316 results
  1. Content Article
    The pilot included five key elements: Conducting semi-structured interviews with a sample of clinical and non-clinical staff who had been directly involved in a patient safety incident, adverse event or medical error in University Hospitals Leicester and Nottingham University Hospital to explore the impact this had on them and the type of support they would have liked to receive. These were transcribed and thematically analysed to identify core themes. Developing a three-tier second victim support programme and including training peer supporters (tier 2). Piloting of the mode
  2. Event
    until
    How looking after staff health and well-being contributes to patient safety. "It’s about a work place that’s more respectful, inclusive and open as a means of creating safety”. Martin Bromiley OBE To deliver high-quality care, the NHS needs staff that are healthy, well and at work. A challenge highlighted further by the pandemic. Join the Clinical Human Factors Group (CHFG) for short and lively presentations, questions and panels with: Rt Hon Jeremy Hunt MP Chair of the Commons Health and Social Care Select Committee Suzette Woodward - culture, conditions and values
  3. Community Post
    I am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focu
  4. Community Post
    A question posed by a delegate at our Patient Safety Learning conference 2019: 'In a publicly funded healthcare system, what role do politicians have in setting culture and improving patient safety?' What are your thoughts?
  5. News Article
    Women in a newly opened psychiatric intensive care unit (PICU) had concerns for their sexual safety, a Care Quality Commission (CQC) report has revealed. Inspectors found women in the PICU at Cygnet Health Care’s Godden Green Hospital, in Kent, were afraid to shower because male staff did not always knock before entering bedrooms and staff entered bathrooms without permission. Patients were often looked after by male staff despite having asked for a female staff member and, in some cases, had an all-male care team. Most patients the inspectors spoke to had concerns about their sexual
  6. Content Article
    Findings In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year. The most common errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nation
  7. Content Article
    Play video The key topics covered in this video are as follows: Why is high-reliability important in addressing avoidable harm? (at 4 mins 25 secs). How culture impacts on the implementation and use of incident reporting solutions (at 8 mins). How incident reporting rates have changed during the pandemic (at 14 mins 25 secs). Positive reporting and learning from success (at 16 mins 25 secs). The role of Board members and non-executive directors understanding of incident reporting and risk management (at 22 mins 50 secs). Considering the importance of
  8. Content Article
    This 5 minute video, from MedStar Health, focuses on the human cost to our healthcare workforce when we fail to cultivate a just culture and systems approach overall, but especially when managing unfortunate harm events. This story has inspired conversation and can be used widely as a teaching tool. When patient harm occurs, caregivers involved are often devastated along with the patient and family, yet many have had to navigate this storm alone. A systems approach in our healthcare workplace, along with the just culture, cultivates the sharing of knowledge and helps prevent patient harm
  9. News Article
    There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the y
  10. News Article
    Action must be taken now if the NHS is to avoid an even worse winter crisis next year, the chief inspector of hospitals has warned. The Care Quality Commission (CQC) said the use of corridors to treat sick patients in A&E was “becoming normalised”, with departments struggling with a lack of staff, poor leadership and long delays leading to crowding and safety risks. Professor Ted Baker said: “Our inspections are showing that this winter is proving as difficult for emergency departments as was predicted. Managing this remains a challenge but if we do not act now, we can predict that ne
  11. Content Article
    Thomas L. Rodziewicz and John E. Hipskind explore medical error prevention in their book and conclude that: All providers (nurses, pharmacists, and physicians) must accept the inherent issues in their roles as healthcare workers that contribute to error-prone environments. Effective communication related to medical errors may foster autonomy and ultimately improve patient safety. Error reporting better serves patients and providers by mitigating their effects. Even the best clinicians make mistakes, and every practitioner should be encouraged to provide peer support to
  12. Content Article
    In this article, Miles suggests that we need to recognise that the culture of any one organisation does not arise in isolation. It is part of, and to some extent derives from, an overarching NHS culture. And the national culture does not always seem to treat patient feedback as a valued resource for learning. Evidence of this includes the following: We tolerate the use of dismissive language. Patient feedback is routinely referred to as 'anecdotal evidence'. That diminishes patient experience, and robs it of its value for learning. We are comfortable with a double standard in use
  13. Content Article
    Wrong tooth extraction has been clearly designated as a 'never event' since April 2015. However, in 2016/17, wrong tooth extraction topped the charts as being the most frequently occurring never event based on NHS England’s data. What can we do to mitigate these incidents? Based on both practical experience and research evidence, BAOS advises that the main methods for mitigation of errors are: learning from mistakes – including investigation and root cause analysis engaging the clinical team when developing 'correct site surgery' policies utilising the LocSSIPs temp
  14. Content Article
    In this short video, Kath Evans explains the importance of working with families to ensure that the safest care to our children and young people is given by healthcare professionals.
  15. Content Article
    In this five minute video, the authors chose to focus on the main theme – the human cost to healthcare workforce when there is a failure to cultivate a just culture and systems approach overall, but especially when managing unfortunate harm events.
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