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Found 206 results
  1. Content Article
    Safety 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.
  2. Content Article
    Published 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.
  3. Content Article
    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.
  4. Content Article
    Charles 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.
  5. Content Article
    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.
  6. Content Article
    At 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.
  7. Content Article
    Annie'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.
  8. Content Article
    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.
  9. Content Article
    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
  10. Content Article
    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. 
  11. Content Article
    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.
  12. Content Article
    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.
  13. Content Article
    Learning from deaths of people in their care can help providers improve the quality of the care they provide to patients and their families, and identify where they could do more.  A CQC review in December 2016, 'Learning, candour and accountability: a review of the way trusts review and investigate the deaths of patients in England'  found some providers were not giving learning from deaths sufficient priority and so were missing valuable opportunities to identify and make improvements in quality of care. This video from the NHS Improvement national patient safety team is a guide for NHS trusts in England on developing and implementing learning from deaths policies within their organisations. 
  14. Content Article
    Health 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.
  15. Content Article
    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.
  16. Content Article
    Safety 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.
  17. Content Article
    This 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?
  18. Content Article
    This 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.
  19. Content Article
    Amy 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.
  20. Content Article
    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.
  21. Content Article
    A 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. 
  22. Content Article
    This 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.
  23. Content Article
    Every 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.
  24. Content Article
    A great  initiative by East Sussex Healthcare NHS Trust to reinforce the importance of basic checks to keep patients from harm when administering medicines.
  25. Content Article
    The 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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