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Showing results for tags 'Safety process'.
Found 208 results
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Content ArticleThis initiative at Chase Farm Hopsital, from the Royal Free NHS Foundation Trust, was started to mitigate wrong implant never events. Instead of just the one person going into the stock room to collect the implant and equipment, two people go and both check. This poster is a gentle reminder to check with a colleague before sending to theatre. What do other Trusts do to mitigate this type of never event?
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Content ArticleRecently, there have been a number of advances in technology, including in mobile devices, globalization of companies, display technologies and healthcare, all of which require significant input and evaluation from human factors specialists. Accordingly, this textbook has been completely updated, with some chapters folded into other chapters and new chapters added where needed. The text continues to fill the need for a textbook that bridges the gap between the conceptual and empirical foundations of the field.
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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 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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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. -
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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Consent: Maternity
Claire Cox posted an article in Consent issues
This area of the Royal College of Obstetricians and Gynaecologists website provides guidance for healthcare professionals on obtaining consent from women within obstetrics and gynaecology services. It provides easy access to all procedure-specific consent documentation and gives advice on how best to support women’s decision-making about their care.- Posted
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Content Article
The ‘C’ word (May 2017)
Claire Cox posted an article in Other countries and national agencies
The ‘c’ word, 'cost' is often used to defend the status quo in patent safety. This article, published by PatientSafe Network, highlights the importance of assessing the financial loss in not introducing the safety intervention. It includes examples on how to overcome barriers like 'we don't have the money for that' when it comes to delivering safer care. After all, the price of safer care is priceless -
Content ArticleAmy Edmondson, PhD, Harvard professor and speaker at Learn Serve Lead 2019: The AAMC Annual Meeting, talks about how to create an interpersonal climate that encourages input from all members of the patient care team.
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How to do Safety-II, a blog by Steven Shorrock
Claire Cox posted an article in Techniques
The patient safety movement started almost fifteen years ago when it was energised by the release of the Institute of Medicine report “To err is human”. Despite efforts since then to improve quality and safety many believe that little progress has been made in reducing harm caused by errors, accidents and unforeseen occurrences. There is a sense of frustration with current approaches to safety (Safety I) and disappointment that more progress has not been made. Recent developments in safety science, termed Safety II, focus on resilience, adaptive capacity and complexity science and show promise for advancing the safety agenda. -
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HMP pulmonary rehabilitation project (February 2015)
Claire Cox posted an article in Prison setting
Here Nina Turner, Healthcare Manager at Rochester Prison discusses how she spotted a gap in healthcare for those in prison. She set up a pulmonary rehabilitation and screening programme for those who smoke in prison. This video sets out how they implemented the project. -
Content ArticleThis report from the Parliamentary Health Service Ombudsman (PHSO) explains the findings of their research, highlights the issues they have identified and sets out the action they believe needs to be taken to improve the quality of NHS investigations.
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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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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. -
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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. -
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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. -
Content ArticleA great initiative by East Sussex Healthcare NHS Trust to reinforce the importance of basic checks to keep patients from harm when administering medicines.
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Content ArticleThe All Party Parliamentary Group (APPG) for Whistleblowing was launched in July 2018 to look at the case for an Independent Office for the Whistleblower. The APPG have set an ambitious workplan aiming to take back the UK’s lead on this legislation, proposing to deliver world class, gold standard draft legislation – a global solution to a global problem. The objectives of the APPG for Whistleblowing are: Influencing policies and decisions that affect whistleblowers globally. Drafting legislation to ensure effective protection for whistleblowers. Commissioning and publishing research, based on our work with whistleblowers and relevant groups and stakeholders across all sectors. Engaging our supporters in campaigns to influence decisions affecting whistleblowers. Giving whistleblowers safe platforms to speak out on issues affecting them. Promoting positive social attitudes towards whistleblowing. Encouraging MPs to promote positive recognition for whistleblowers. Supporting and upskilling MPs and their staff to identify and manage constituent whistleblower cases.
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Content ArticleA report for Norfolk and Suffolk NHS Foundation Trust by Verita. Verita is an independent consultancy that specialises in conducting and managing investigations, reviews and inquiries for regulated organisations.
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Content ArticleThis policy confirms the process for reviewing deaths within Lincolnshire Community Health Services (LCHS) to ensure a consistent approach is followed in order to identify if the patient’s needs were met during the end of life phase and that relatives and carers were supported appropriately. The aim of the mortality review process is to identify any areas of practice that require improvement and to identify areas of good practice. This process ensures that mortality within LCHS is managed and reviewed in a systematic way.
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Content ArticleHealth and social care providers internationally are heavily scrutinised by external regulators as part of accreditation, inspection and external review processes. The aims are generally to identify poor performance and/or to improve performance and in particular to ensure the delivery of good quality services. This can result in a complex, costly and overlapping network of oversight arrangements. In his editorial, published by the Journal of Health Services Research & Policy, Sheldon discusses this topic further.
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Content ArticleFor the past two years, Scalpel Ltd have been building technologies that improve patient safety in surgery. We have found a lack of understanding of why we need to invest in patient safety. In this blog I discuss surgical errors and the urgent need to invest in patient safety.
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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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Freedom to Speak Up Guardian job description (March 2018)
Claire Cox posted an article in Speak Up Guardians
This is the Freedom to Speak Up Guardian job description. Use it for reference or for a template to advertise for a Freedom to Speak Up Guardian in you trust/sector. -
Content ArticleEvery safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. This paper from Almaberti et al. Implementation Science published attempts to reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.
