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Showing results for tags 'Safety process'.
Found 209 results
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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.
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Content ArticleCollecting feedback on the care provided to bereaved families and carers following the death of a child or young person is of critical importance to improving bereavement care. Whilst some local healthcare systems have well-established mechanisms and questionnaires for collecting such feedback, many have indicated that they do not and would value guidance in this area.
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Rethinking Patient Safety by Suzette Woodward
Claire Cox posted an article in Recommended books and literature
The vast majority of healthcare is provided safely and effectively. However, just like any high-risk industry, things can and do go wrong. There is a world of advice about how to keep people safe but this delivers little in terms of changed practice. Written by Suzette Woodward, a leading expert in the field with over two decades of experience, Rethinking Patient Safety provides readers with a critical reflection upon what it might take to narrow the implementation gap between the evidence base about patient safety and actual practice. This book provides important examples for the many professionals who work in patient safety but are struggling to narrow the gap and make a difference in their current situation. It provides insights on practical actions that can be immediately implemented to improve the safety of patient care in healthcare and provides readers with a different way of thinking in terms of changing behaviour and practices as well as processes and systems. Suzette Woodward shares lessons from the science of implementation, campaigning and social movement methods and offers the reader the story of a discovery. Her team has explored an approach which could profoundly affect the safety culture in healthcare; a methodology to help people talk to each other and their patients and to listen through facilitated safety conversations. This is their story. -
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Whistleblowing disclosures joint report 2019
Patient Safety Learning posted an article in Whistle blowing
On April 1 2017, a new legal duty came into force which required all prescribed bodies to publish an annual report on the whistleblowing disclosures made to them by workers. The Nursing and Midwifery Council has published a a joint whistleblowing disclosures report with other healthcare regulators. The aim in this report is to be transparent about how we handle disclosures, highlight the action taken about these issues, and to improve collaboration across the health sector. As each regulator has different statutory responsibilities and operating models, a list of actions has been devised that can accurately describe the handling of disclosures in each organisation. -
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NHS Improvement: Elective care pathway analyser (updated 10 April 2019)
Claire Cox posted an article in Processes
NHS Improvement has devised an elective care pathway analyser tool which will support critical review of any clinical pathway (including administrative and process steps) across all types of elective pathway, including referral to treatment (RTT), diagnostics and cancer, and help identify high impact interventions. -
Content ArticleIn this commentary, I reflect on how we may all suffer from some degree of professional complacency. Healthcare professionals do not get up in the morning intending to harm anyone, but normal human liabilities can impair our performance. We may often fail to recognise environmental and situational risks, and, more importantly, to admit to our own personal liabilities and, thus, the risks we bring into the healthcare environment.
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10,000 feet - Patient Safety in the operating theatre
Claire Cox posted an article in Process improvement
This video by theatre staff from East Lancashire Hospitals NHS Trust explains how the 10,000 feet initiative promotes patient safety within the operating theatre. -
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Impact of the new medical examiner role on patient safety
Claire Cox posted an article in Organisational
In an analysis published in the BMJ, Alan Fletcher and colleagues outline how the new medical examiner system could create a world leading mortality review system if implemented appropriately. -
Content ArticleNever Events are patient safety incidents that are considered preventable when national guidance or safety recommendations that provide strong systemic protective barriers are implemented by healthcare providers.
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Content ArticleNational bodies can provide systems and policies for the NHS, but safety is improved at the point of care. Lauren Mosley, Head of Patient Safety Implementation, and Donna Forsyth, Head of Investigation, describe the new Patient Safety Incident Response Framework (PSIRF).
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Content ArticleThere has been growing interest in the concept of safety cases for medical devices and health information technology, but questions remain about how safety cases can be developed and used meaningfully in the safety management of healthcare services and processes. This paper in Reliability Engineering & System Safety presents two examples of the development and use of safety cases at a service level in healthcare. These first practical experiences at the service level suggest that safety cases might be a useful tool to support service improvement and communication of safety in healthcare. Sujan et al. argue that safety cases might be helpful in supporting healthcare organisations with the adoption of proactive and rigorous safety management practices. However, it is also important to consider the different level of maturity of safety management and regulatory oversight in healthcare. Adaptations to the purpose and use of safety cases might be required, complemented by the provision of education to both practitioners and regulators.
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Content ArticleThe creation of a national network of medical examiners (MEs) was recommended in the Shipman inquiry and was alluded to in the Mid-Staffordshire and Morecambe Bay public inquiries. The Parliamentary Under-Secretary of State for Health, Lord O’Shaughnessy, confirmed in October 2017 that a national system of medical examiners will be introduced from April 2019. The ME reforms set out in the 2009 Coroners Act will be implemented nationally in two phases. By April 2019, NHS trusts should set up non-statutory schemes, based upon the national pilots (particularly in Leicester, Sheffield and Gloucester), funded in part from cremation form fees, in preparation for the commencement of a statutory scheme in 2020/21. A National Medical Examiner will be appointed, reporting directly to the National Director of Patient Safety.
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Content ArticleCharles Vincent and René Amalberti set out a system of safety strategies and interventions for managing patient safety on a day-to-day basis and improving safety over the long term. These strategies are applicable at all levels of the healthcare system from the frontline to the regulation and governance of the system. There have been many advances in patient safety, but we now need a new and broader vision that encompasses care throughout the patient’s journey. The authors argue that we need to see safety through the patient’s eyes, to consider how safety is managed in different contexts and to develop a wider strategic and practical vision in which patient safety is recast as the management of risk over time. Most safety improvement strategies aim to improve reliability and move closer toward optimal care. However, healthcare will always be under pressure and we also require ways of managing safety when conditions are difficult. We need to make more use of strategies concerned with detecting, controlling, managing and responding to risk. Strategies for managing safety in highly standardised and controlled environments are necessarily different from those in which clinicians constantly have to adapt and respond to changing circumstances.
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Promote a culture of safety with good catch reports
Claire Cox posted an article in In health care
Near misses or good catches present organisations with learning opportunities. Using data comparisons run by the Pennsylvania Patient Safety Authority, this article by Wallace et al. highlights how good catch programmes can contribute to significant reductions in harmful events and offers insights from risk managers and patient safety officers regarding elements that are necessary to establish successful good catch initiatives and the culture to support them. -
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Complicated and complex systems in safety management
Claire Cox posted an article in Organisational
This blog by Adam Johns, Safety and Risk Manager for Cathay Pacific Airways, discusses the differences between complicated and complex systems and how this impacts on the way we manage safety and risk. -
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West of England AHSN: PReCePT resources
Claire Cox posted an article in Health Innovation Networks (formerly AHSNs)
The PReCePT Programme is a quality improvement project designed to reduce the incidence of cerebral palsy through the administration of magnesium sulphate to eligible preterm mothers across England. -
Content ArticleFollowing the investigation into the Mid Staffordshire Hospital (United Kingdom) and the subsequent Francis reports (2013 and 2015), all healthcare staff, including students, are called upon to raise concerns if they are concerned about patient safety. Despite this advice, it is evident that some individuals are reluctant to do so and the reasons for this are not always well understood. This research study from Fisher and Kiernan, published in Nurse Education Today, provides an insight into the factors that influence student nurses to speak up or remain silent when witnessing sub-optimal care.
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Content ArticleThis is the first of a series of blogs on improvement of systems by Dr Rhidian Bramley. This introductory post looks at the drivers and some of the core concepts around designing clinical workflow in an electronic healthcare record (EHR) system. Dr Rhidian Bramley is a consultant radiologist and associate medical director at the Christie NHS Foundation Trust.
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Content ArticleProfessor Alison Leary, Chair of Healthcare & Workforce Modelling, London South Bank University, delivers the James Reason lecture at the 2018 HSJ Patient Safety Congress on work force and safety and discusses the complexity of demand.
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Content ArticleThe Clinical Human Factors Group (CHFG) had a fantastic one-day conference looking at how design and procurement in medical devices and systems can proactively improve patient safety. Here are the presentations, slides and interviews.
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Content ArticleAt a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved. This is the first book to provide detailed guidance on how to conduct incident investigations in primary care. The concise guide: explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies covers the technical aspects of serious incident recognition and report writing includes a wealth of practical advice and 'top tips', including how to manage the common pitfalls in writing reports offers practical advice as well as some new and innovative tools to help make the RCA process easier to follow explores the all-important human factors in clinical incidents in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis. This book offers a master class for anyone performing root cause analysis and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any clinical or governance leads in primary care, including GP practices, 'out-of-hours', urgent care centres, prison health and NHS 111. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.
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Content ArticleThe National Guardian’s Office (NGO) conducted a review of the handling of speaking up at Derbyshire Community Health Services Foundation Trust after receiving information that the trust might not have responded to one of its workers speaking up in accordance with good practice. The review sought to identify learning on how support for speaking up could be improved, as well as to highlight existing good practice.
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Content ArticleSince the Government initially consulted on the package of Death Certification Reforms, new information about how Medical Examiner (ME) system could be introduced has been generated by the Department of Health and Social Care (DHSC), ME pilot sites, early adopters of the ME system, as well as from the Learning from Deaths initiative. This case study outlines the approach of South Tees Hospitals NHS Foundation Trust as one of the early adopter sites.
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Patient safety and quality - NHS Leeds Clinical Commissioning Group
Claire Cox posted an article in CCGs
This web page describes how NHS Leeds monitors safety and quality. -
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The Heinrich/Bird safety pyramid
Claire Cox posted an article in In health care
Herbert W. Heinrich was a pioneering occupational safety researcher, whose 1931 publication, Industrial Accident Prevention: A Scientific Approach [Heinrich 1931] was based on the analysis of accident data collected by his employer, a large insurance company.
