Attached is a presentation (December 2019) by Andrew Pepper-Parsons, Head of Policy at Protect. The presentation outlines Protect's Better Regulators Campaign.
The objectives of the campaign are to:
start to create a more consistent approach in how whistleblowers are interacted with
set and shape the standards expected from internal whistleblowing processes
start a dialogue between the regulators themselves and with Protect.
The Authors, conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff well-being. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to p
In two studies, researchers found that doctors with high levels of burnout had between 45% and 63% higher odds of making a major medical error in the following three months, compared with those who had low levels.
To ensure well-being and motivation at work, and to minimise workplace stress, people have three core needs, and all three must be met.
A - Autonomy/control – the need to have control over our work lives, and to act consistently with our work and life values.
B - Belonging – the need to be connected to, cared for, and caring of others around us in the workplace and to
This paper presents eight steps that are recommended for leaders to follow to achieve patient safety and high reliability in their organisations. Each step and its component parts are described in detail in the sections that follow, and resources for more information are provided where available.
Address strategic priorities, culture and infrastructure.
Engage key stakeholders.
Communicate and build awareness.
Establish, oversee and communicate system-level aims.
Track/measure performance over time, strengthen analysis.
Support staff and patients/families im
What will I learn?
History of sepsis guidance
Oxford AHSN approach to implementation of the guidance
Care bundles (resource)
Regional pathway for sepsis
How to measure surveillance
Limitations of coding sepsis
This virtual masterclass, facilitated by Mr Perbinder Grewal, will focus on patient safety and how to setup a proactive safety culture. It will look at what patient safety is and how to setup and improve the safety culture. It will look at Human Factors and how to mitigate some of the common errors. Can we have a system with zero patient safety incidents or errors?
Further information and book your place or email email@example.com
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The content covers six characteristics fundamental to a healthy culture:
Inspiring vision and values
Goals and performance
Support and compassion
Learning and innovation
Drawing on a dizzying array of case studies and real-world examples, together with cutting-edge research on marginal gains, creativity and grit, Matthew Syed tells the inside story of how success really happens - and how we cannot grow unless we are prepared to learn from our mistakes.
The guide is for anyone involved with patient engagement, including:
patients and families interested in how to partner in their own care to ensure safety
patient partners interested in how to help improve patient safety
providers interested in creating collaborative care relationships with patients and families
managers and leaders responsible for patient engagement, patient safety, and/or quality improvement
anyone else interested in partnering with patients to develop care programs and systems.
While the guide focuses primarily on patient safety, many engag
AAR is a deceptively simple process for learning from any every day or exceptional 'action', which takes the individual expectations and experiences of the same event to build a shared mental model of what happened and use this as the basis for learning and action planning. To be successful it is essential that AARs are led by a trained AAR 'Conductor' who uses a defined four-question process and a universal set of AAR 'ground rules' to create a safe learning environment. The other vital component, which is often missing, is the organisational context in which the AARs take place. This needs t
Organisational culture is the essential element in meeting healthcare goals, according to Stephen Swensen, Professor Emeritus at the Mayo Clinic College of Medicine and Senior Fellow at the Institute for Healthcare Improvement. “Culture, more than anything else, drives performance,” he says.
In that context, it is notable that culture at many healthcare organisations is changing, and in the right direction, say nearly 60% of respondents to the latest NEJM Catalyst Insights Council survey. Three-quarters of respondents (clinical leaders, clinicians, and executives from organisations direct
Practical guidance on the application of human factors in the investigation process is presented.
Nine principles for incorporating human factors into learning investigations are identified:
1. Be prepared to accept a broad range of types and standards of evidence.
2. Seek opportunities for learning beyond actual loss events.
3. Avoid searching for blame.
4. Adopt a systems approach.
5. Identify and understand both the situational and contextual factors associated with the event.
6. Recognise the potential for difference between the way work is imagined and t