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Found 530 results
  1. Content Article
    This scoping paper explores the question ‘what would it take to build a culture of learning at scale?’. It focuses on systems-wide learning that can help to inform systems change efforts in complex contexts. To answer this question, literature was reviewed from across diverse disciplines and the realms of education, innovation systems, systems thinking and knowledge management. This inquiry was also supported by in-depth interviews with numerous specialists from the for-purpose sector and the examination of several case studies of learning across systems. The goal was to derive common patterns to inform a ‘learning for systems change’ framework.  In this paper, a ‘learning networks’ approach is proposed, one that draws upon individual, group and systems-wide learning to build capacity and resilience for systems change in uncertain environments. This fills a gap in the literature where the focus is largely on learning within organisations. Instead, the focus here is on what is required to support learning to occur across scales and boundaries - from the individual to system-wide. A simple meta-framework for developing learning networks is proposed that includes high level guidance on the enabling conditions - the mindsets, relationships, processes and structures - that would enable learning networks to flourish.
  2. Content Article
    Colette Longstaffe, a registered nurse working in NHS Supply Chain in the Clinical and Product Assurance Team (CaPA), discusses how medical device design can impact on usability and patient safety, and the importance of embedding human factor principles into product specifications for the NHS procurement frameworks.
  3. Content Article
    This systematic review in Nursing Open synthesises the best available evidence on the impact of nurses' safety attitudes on patient outcomes in acute care hospitals. The review included nine studies and found that nurses with positive safety attitudes reported: fewer patient falls and medication errors fewer pressure injuries and healthcare-associated infections fewer mortalities fewer physical restraints and vascular access device reactions higher patient satisfaction. The authors also found that effective teamwork led to a reduction in adverse patient outcomes. They conclude that a positive safety culture results in fewer reported adverse patient outcomes, and that nurse managers can improve nurses' safety attitudes by promoting a non-punitive response to error reporting and promoting effective teamwork and good communication.
  4. Content Article
    In this blog Patient Safety Learning’s Chief Executive, Helen Hughes, reflects on her recent experience attending a meeting of the Patient Safety Management Network and hearing about the work of the Quality and Safety Department at the Sussex Community NHS Foundation Trust.
  5. Content Article
    This is a presentation given by the Quality and Safety Department at the Sussex Community NHS Foundation Trust to the Patient Safety Management Network on 22 October 2021. It provides an overview of how they have been developing the Trust’s approach to patient safety, focusing on safety culture, learning for improvement and aiming to raise the profile of patient safety within their organisation.
  6. Content Article
    This document from the World Health Organization raises awareness about strategies that could reduce diagnostic errors in primary care. It highlights the importance of examining diagnostic errors, identifies the most common types of diagnostic error in primary care and describes potential solutions.
  7. Content Article
    Numerous studies show a link between a positive safety culture (where safety is a shared priority) and improved patient safety within a healthcare organisation. The evidence is so convincing that the US National Patient Safety Foundation (NPSF) lists leadership support for a safety culture as the most important of eight recommendations for achieving patient safety. This overview from the Emergency Care Research Institute (ECRI) provides guidance and recommendations on how to embed approaches to safety culture within healthcare organisations.
  8. Content Article
    In this blog, Claire Cox, Quality Improvement and Patient Safety Manager at Guys and St Thomas' Hospital NHS Foundation Trust, explains why and how she developed the Patient Safety Management Network. She looks at why the network is needed, what it has achieved so far, its aims for the future and how patient safety managers can get involved.
  9. Content Article
    A Patient Safety Huddle is a brief multidisciplinary daily meeting held to discuss threats to patient safety and actions to mitigate risk. This evaluation of The Huddle Up for Safer Healthcare (HUSH) project in BMC Health Services Research aims to assess the impact on teamwork and safety culture of the project, which implemented PSHs in 92 wards at five hospitals, across three NHS Trusts. This paper also seeks to add to the evidence-base around huddles as a mechanism for improving safety.
  10. Content Article
    This systematic review in BMJ Quality & Safety looks at existing research into the impact of hospital-based safety huddles. The authors found that while there are many anecdotal accounts of successful huddle programmes, there is not yet much high-quality peer-reviewed evidence regarding the effectiveness of hospital-based safety huddles. They suggest that additional rigorous research is needed to enhance collective understanding of how huddles impact patient safety and other outcomes. The review proposes a taxonomy and standardised reporting measures for future studies, to enhance comparability and evidence quality.
  11. Content Article
    This white paper sets out the symbiotic relationship between healthcare worker safety and patient safety. It makes the case for a new focus on improvements in patient and healthcare worker safety, and on the relationship between them, to prevent safety incidents and deliver better outcomes for all. It has been published by the Safety for All campaign, set up by the Safer Healthcare and Biosafety Network (SHBN), an independent forum focused on improving healthcare worker and patient safety, including Patient Safety Learning and the Association of British HealthTech Industries.
  12. Content Article
    Poster presented by hub topic lead, Hugh Wilkins, at the MPEC 2021 Conference.
  13. Content Article
    This blog for the High Reliability Organizing website looks at the implications of 'preoccupation with failure' for individuals and organisations. The author highlights examples of how preoccupation with failure, as first described by Karl Weick and Kathleen Sutcliffe, can improve outcomes and reduce costs in healthcare organisations and in other sectors. She identifies barriers to organisations engaging with the process, including reluctance to look for 'hidden failures' and poor communication.
  14. Content Article
    This Annual Quality Statement provides a summary of the work of Cardiff and Vale University Health Board in 2019-2020, with a particular focus on community mental health.
  15. Content Article
    This study, published in Leadership in Health Services, assesses how patient safety culture and incident reporting differ across professional groups and between long-term and acute care. It used the Hospital Survey on Patient Safety Culture questionnaire to assess patient safety culture in long-term care (wards and nursing homes) and acute hospital settings at one Finnish healthcare organisation. The authors highlight that this study reveals differences in safety culture between acute care and long-term care settings, and between professionals and managers. They also note that staff involved in the study did not feel they were given enough feedback about reported incidents by managers.
  16. Content Article
    This study, published in the International Journal for Quality in Health Care, examined the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences. It highlighted the complexities involved and the difficulties faced by staff in learning from incident data.
  17. Content Article
    This article, published by the BMJ, discusses mandatory and voluntary medical error reporting programmes and comments that voluntary reporting by practitioners is usually more useful.
  18. Content Article
    Current research suggests that staff mindfulness practices can contribute to better safety outcomes. Researchers at the University of Houston have conducted a systematic review of studies that assess the relationship between mindfulness and safety at work. The study suggests that: mindfulness training does not need to be lengthy or frequent to have a significant impact on workplace safety different mindfulness training techniques are better suited to specific industries such as healthcare and the military.
  19. Content Article
    This new book by Professor Harold Thimbleby of Swansea University tells stories of widespread problems with digital healthcare and explores how they can be overcome. "The stories and their resolutions will empower patients, clinical staff and digital developers to help transform digital healthcare to make it safer and more effective."
  20. Content Article
    In this systematic review published in BMJ Open, the authors analyse and compare the focus of 694 studies about safety culture in hospitals. The review identifies 11 key themes relating to safety culture across the studies. The authors suggest that the wide range of methods and tools available highlights a persistent lack of consensus in defining patient safety. They also highlight the value of qualitative and mixed method approaches in providing context and meaning to quantitative surveys that assess safety culture.
  21. Content Article
    This paper discusses the use of safety culture assessment as a tool for improving patient safety. It describes the characteristics of culture assessment tools currently available and discusses their current and potential uses, including brief examples from healthcare organisations that have used them. It also highlights critical processes that healthcare organisations need to consider when deciding to use these tools. The authors highlight safety culture assessment as the starting point for patient safety changes. They suggest that safety culture assessment is useful if it: involves key stakeholders uses a suitable safety culture assessment tool uses effective data collection procedures implements action planning and initiates change.
  22. Content Article
    It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."
  23. Content Article
    A film about why Schwartz Rounds are needed.
  24. Content Article
    In this video, Helen Hughes, Chief Executive of Patient Safety Learning, speaks to Phil Taylor, Chief Product Officer at RLDatix, about the importance of culture in achieving high reliability in healthcare. They discuss the impact of culture on incident reporting, examples of where safety culture is key to making improvements and consider what is needed to create the right safety culture.
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