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Content Article
Non-Technical Skills for Surgeons (NOTSS)
Patient Safety Learning posted an article in In surgery
The non-technical skills of surgeons (NOTSS) play a significant role in patient safety. The aim of the NOTSS project was to develop and test an educational system for assessment and training of non-technical skills in the intra-operative phase of surgery. NOTSS is a behaviour rating system based on a skills taxonomy that allows valid and reliable observation and assessment of four categories of surgeons' non-technical skill: situation awareness, decision making, communication & teamwork, and leadership. These are the essential non-technical skills surgeons need to perform safely in the operating room and NOTSS allows measurement of several ACGME (Accreditation Council for Graduate Medical Education) competencies, including professionalism, interpersonal and communication skills, and systems-based practice. The skills taxonomy can be used to structure training and assessment in this important area of surgical competence. -
Content ArticleHealth Education England (HEE) has published a suite of resources to help support workers, employers, and integrated care systems (ICSs) prepare for the implementation of HEE’s Allied Health Profession (AHP) Support Worker Competency, Education and Career Development Framework.
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Content ArticleWe have probably all suffered from imposter syndrome at some point during our career. Doubted our self and our abilities. However, if we aren't confident in ourselves and how we do our jobs it could impact on the patients we look after. Here are my tips on how to get to grips with your imposter syndrome.
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Content ArticleWhile the benefits of psychological safety are well established, a new survey suggests how leaders, by developing specific skills, can create a safer and higher-performance work environment.
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Content ArticleHuman Factors and ergonomics (HFE) expertise continues to have difficulty integrating its experts into healthcare. This persistent disconnect is compounded by unique aspects of healthcare as an institution, industry and work system. Clinically embedded HFE practitioners, a new HFE sub-specialty, are a conduit for addressing substantive mismatches between the two domains. Greater HFE penetration will require a fundamental change in stance for both domains, however, the burden will lie with HFE to be the more adaptive of the two. Learning more about the in situ work of this sub-specialty will provide insights for more nuanced approaches to bridging domain specific mismatches and obstacles.
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Event
Learning pathway for healthcare
Sam posted an event in Community Calendar
untilWhat do you need to know to be safe at work? We all have different roles in healthcare to provide clinical care and treatment; support services, maintenance, purchasing, communication and IT support. Some of us are employed to provide specific safety information and advice (e.g. fire safety, infection prevention). This webinar from the Q Community will introduce an accredited learning pathway for everyone. Level 1 (one hour online e-learning) introduces a new way of thinking about safety using Human Factors. Level 2 & 3 introduce more detail and integrate capabilities from the National Patient Safety Syllabus. By Level 3, you could be a Technical Specialist (Healthcare) with the Chartered Institute of Ergonomics & Human Factors. Further information Register -
Content ArticleSue Hignett and Paul Bowie propose taking a much-needed professional approach to patient safety through an accredited learning pathway to integrate safety into clinical systems and develop healthcare safety specialists and experts
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EventuntilWe know that it is no longer enough just to have a good idea; just as important is the ability to work collaboratively with others, to navigate organisational politics and to work with relational dynamics to use that idea to create change. In the midst of a global pandemic, where new organisational arrangements have changed familiar lines of authority and where leadership takes place predominantly from behind a computer screen, opportunities for influencing can be fraught with dilemmas and frustrations as well as bringing opportunities for innovation and new ways of working. This programme from the King's Fund will enable you to work more effectively in the gap between your commitment and enthusiasm for change and the reality of making things happen within the constraints of your role and wider system priorities. Register
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News ArticleFor the last 10 months, everyone in healthcare has lived their lives as if they were trapped in a burning building without a fire escape. No matter how much water we throw on the fire or how many firefighters (healthcare providers in this instance) we send in, we cannot gain control of the flames. The catastrophic loss of life has been insurmountable, and we often haven’t had enough physicians to take care of everyone. This is not new for a healthcare system. For years prior to this pandemic, there has been a physician shortage in the United States that is expected to worsen over the coming years. The Association of Medical Colleges (AAMC) predicts that the US could see a shortage between 54,000 and 139,000 physicians in both primary and specialty care by 2033. Although the total physician supply is expected to grow, it won’t be at a fast enough rate to outpace demand. This is where physician assistants (PAs) and advanced practice nurses (APRNs) come in. Many people don’t realise that PAs and APRNs have been around for over 50 years. For 50 years, a plethora of research has shown that PAs and APRNs are safe, reliable, high quality healthcare providers and essential members of the healthcare team. But too often critics claim that because they have not gone through physician training, they cannot provide exceptional medical and surgical care. In fact, they already do. A recent comprehensive review of PA and APRN outcomes from 2008 to 2018 found that PAs and APRNs had similar outcomes compared to physicians including hospital length of stay, readmission rates, quality and safety and patient and staff satisfaction. Read full story Source: The Hill, 16 January 2021
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Content ArticleFollowing the publication of Donna Ockenden’s first report: Emerging Findings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospitals NHS Trust on 11 December 2020, the NHS has issued this latest update. Read previous letter update
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EventuntilThe uncertainty and anxiety that come with the experience of complexity can be overwhelming. It can be hard to think clearly and act wisely, and our wellbeing can easily suffer. The COVID-19 pandemic has made these experiences an everyday occurrence for many people, and the need for us to work clearly, wisely and healthily has never been more pressing. These Organisational Development workshops from the King's Fund will lift the lid on complexity. Together, you’ll explore how encouraging ourselves and others to understand and acknowledge the loss of control when faced with complexity can help us, our teams and our wider organisational systems survive and even thrive in conditions of uncertainty. The workshops will help you: make sense of the messy reality of complexity, accurately categorise different aspects of that reality and be able to choose appropriate, measured, responses understand your own preferences and strengths in relation to the complexity around you and develop strategies to stretch beyond them help yourself and others be their best during uncertain times. Join one or two sessions, or the whole series. Buy tickets
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EventThe uncertainty and anxiety that come with the experience of complexity can be overwhelming. It can be hard to think clearly and act wisely, and our wellbeing can easily suffer. The COVID-19 pandemic has made these experiences an everyday occurrence for many people, and the need for us to work clearly, wisely and healthily has never been more pressing. These Organisational Development workshops from the King's Fund will lift the lid on complexity. Together, you’ll explore how encouraging ourselves and others to understand and acknowledge the loss of control when faced with complexity can help us, our teams and our wider organisational systems survive and even thrive in conditions of uncertainty. The workshops will help you: make sense of the messy reality of complexity, accurately categorise different aspects of that reality and be able to choose appropriate, measured, responses understand your own preferences and strengths in relation to the complexity around you and develop strategies to stretch beyond them help yourself and others be their best during uncertain times. Join one or two sessions, or the whole series. Buy tickets
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Content Article
Article: Culture, kinship and intelligent kindness (2013)
Patient-Safety-Learning posted an article in Culture
This article by Penny Campling for the Royal College of Psychiatrists suggests that cultivating a culture of 'intelligent kindness' within the NHS will result in more safe and humane care. The author proposes a 'virtuous circle of compassionate care' and highlights systemic barriers that prevent organisations achieving this ideal. She argues that to create this virtuous circle, healthcare professionals need to acknowledge - and consciously work against - structures that undermine kindness. This requires a greater understanding the emotional impact of healthcare work, an acknowledgement that market culture undermines compassionate care and a renewed focus on relationships between professionals.- Posted
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Content ArticleDespite the application of a huge range of human factors (HF) principles in a growing range of care contexts, there is much more that could be done to realise this expertise for patient benefit, staff well-being and organisational performance. Healthcare has struggled to embrace system safety approaches, misapplied or misinterpreted others, and has stuck to a range of outdated and potentially counter-productive myths even has safety science has developed. One consequence of these persistent misunderstandings is that few opportunities exist in clinical settings for qualified HF professionals. Instead, HF has been applied by clinicians and others, to highly variable degrees—sometimes great success, but frequently in limited and sometimes counter-productive ways. Meanwhile, HF professionals have struggled to make a meaningful impact on frontline care and have had little career structure or support. However, in the last few years, embedded clinical HF practitioners have begun to have considerable success that are now being supported and amplified by professional networks. The recent COVID-19 experiences confirm this. Closer collaboration between healthcare and HF professionals will result in significant and ultimately beneficial changes to both professions and clinical care.
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Content Article
Safer Anaesthesia From Education (SAFE)
Patient Safety Learning posted an article in In surgery
Safer Anaesthesia From Education (SAFE) is a joint project developed in 2011 by the Association of Anaesthetists and the WFSA (World Federation of Societies of Anaesthesiologists). The training initiative aims to bring practitioners of obstetric and paediatric anaesthesia (who throughout the world may be physician anaesthesiologists but are largely non-physicians) to a level of practice whereby they can deliver vigilant, competent, and safe anaesthesia. The underlying principle is to equip anaesthetists with the essential knowledge and skills so they can deliver safe care to their patients, even in very low resource settings, and to train as many anaesthesia providers as possible in each country in order to create a sustainable training model which can be embedded in the national health system.- Posted
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Content Article
Implementing a District and Community Nursing workload tool, to determine safe staffing levels and skill mix in a community care provider organisation. An economic assessment of potential benefits for workforce planning (February 2016)
Patient Safety Learning posted an article in Safe staffing levels
Achieving safe district and community nurse caseloads, staffing levels and skill mix in order to deliver the increasing demand for care close to or in the home are a key challenge for primary and community care organisations in the UK. However there is a national crisis in relation to robust workforce evidence due to a lack of tools available to capture the complexity of care being delivered in different geographical locations to meet rural and urban patient population need. This paper presents a case study to illustrate the potential benefits of implementing Cassandra, a community workload analysis tool in one community provider organisation in the south of England. The Cassandra tool provides potential to: i) model the multidimensional complexity of care in different contexts and populations; ii) develop a potential blueprint for robust monitoring of decisions related to safe caseloads, staffing levels and skill mix; iii) when triangulated with other metrics, provides additional value to organisations as it enables an accurate picture to be created to monitor safe caseload, staffing levels, skill mix and competence and impacts on quality of patient care and commissioning of services in different geographies. As a place based demand tool this offers real opportunity to improve the evidence base of workforce planning and development driven by the needs of community populations.- Posted
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News ArticleHealth chiefs are designing an “early warning” system to detect and prevent future maternity care scandals before they happen, a health minister has said. Patient safety minister Nadine Dorries said she hoped the system would highlight hospitals and maternity units where mistakes were being made earlier. The former nurse also revealed the Department of Health and Social Care was drawing up a plan for a joint national curriculum for both midwives and obstetricians to make sure they had the skills to look after women safely. During a Parliamentary debate following the publication of a report into the Shrewsbury and Telford Hospital care scandal, the minister was challenged by MPs to take action to prevent future scandals. The former health secretary, Jeremy Hunt, warned the failings at the Shropshire trust, where dozens of babies died or were left with permanent brain damage, could be repeated elsewhere. He said: “The biggest mistake in interpreting this report would be to think that what happened at Shrewsbury and Telford is a one-off — it may well not be, and we mustn't assume that it is.” Ms Dorries said: “Every woman should own her birth plan, be in control of what is happening to her during her delivery and I really hope ... this report is fundamental in how it's going to reform the maternity services across the UK going forward. Read full story Source: The Independent, 11 December 2020
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News Article
New trust’s ‘inexperienced’ leadership criticised as CQC serves warning
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has criticised a new trust’s leadership after issuing it with a warning notice to improve care in its two emergency departments. The watchdog warned North Cumbria Integrated Care Foundation Trust that patients were not always receiving timely and appropriate care, while delayed transfers of care had “resulted in significant delays in admitting patients on to wards”. The CQC — which carried out focused inspections at the trust in August and September after concerns were raised about risks to patient and staff safety — added there was evidence of “insufficient numbers of suitably qualified, skilled, competent and experienced clinical staff”. The CQC also said there was a lack of an effective system to mitigate risks, including infection control in the emergency department escalation areas and on some medical wards. Of the trust’s Cumberland Infirmary and West Cumberland hospitals, the CQC said: “People could not access the urgent and emergency care and medicine service when they needed them and often had long waits for treatment.” The CQC’s inspection report, published today, also said the trust had an “inexperienced leadership team” which “did not always have the necessary skills and abilities to lead effectively”. It added there were “few examples of leaders making a demonstrable impact on the quality or sustainability of services”. Read full story (paywalled) Source: HSJ, 30 November 2020- Posted
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News Article
Barnsley care agency 'recruitment procedures unsafe'
Patient Safety Learning posted a news article in News
A care agency which left people "at risk of avoidable harm" by not ensuring staff had been properly trained has been put into special measures. Stars Social Support, which provides personal care to people living in their own home, was inspected by the Care Quality Commission earlier this year. Inspectors found safe recruitment procedures were not in place to make sure suitable staff were employed. A report following the inspection states that "safe recruitment procedures were not in place to ensure only staff suitable to work in the caring profession were employed." It said people's references had not been followed up after they had been requested, according to the Local Democracy Reporting Service. The report added: "When the disclosure and barring service (DBS) identified concerns, a risk assessment had not been completed to assess staff suitability." Inspectors also found not all staff who provided care had received appropriate training or training updates to ensure they were competent. Read full story Source: BBC News, 21 November 2020- Posted
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Content ArticleIt is estimated that across the UK, a third of healthcare improvement projects never spread beyond their particular unit, a further third are embedded across their organisation but never spread further than that, and only the final third are spread across their own and other similar organisations. Successfully spreading improvements and ensuring changes are sustained requires overcoming numerous challenges, such as: Creating an awareness of why the change is needed Ensuring those involved have a desire to support and participate in the change Knowledge of how to bring about change The skills and resources to bring about the change Ensuring processes to sustain the change This new guide from the West of England AHSN sets out suggestions to be considered for the successful adoption and spread of innovation and improvement projects.
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Content ArticleNina Hemmings responds to the 'State of the adult social care workforce report' from Skills for Care.
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Content ArticleThe Health Service Executive (HSE) Dublin North East’s Patient Safety Tool Box Talks have been developed to assist with the delivery of key patient safety messages within the workplace. Patient Safety Tool Box Talks© are not a substitute for formal training but rather recognises the need to embed patient safety into the workplace and as such are a support to formal more detailed training programmes. This approach allows the delivery of consistent short customised patient safety messages to staff in a brief intervention as part of a team meeting or at a shift change. The talks are designed to take no more that 5-10 minutes to deliver are capable of being delivered by a non-specialist. If questions however arise beyond the scope of the talk these should be referred to a specialist for clarification. This Tool Box also contains Guidance on Delivering a Patient Safety Tool Box Talk© and a number of talks on a variety of safety topics.
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News Article
The medical school trying to become anti-racist
Patient Safety Learning posted a news article in News
A major British medical school is leading the drive to eliminate what it calls "inherent racism" in the way doctors are trained in the UK. The University of Bristol Medical School says urgent action is needed to examine why teaching predominantly focuses on how illnesses affect white people above all other sections of the population. It comes after students pushed for reform, saying gaps in their training left them ill-prepared to treat ethnic minority patients – potentially compromising patient safety. Hundreds of other UK medical students have signed petitions demanding teaching that better reflects the diversity of the country. The Medical School Council (led by the heads of UK medical schools) and the regulator, the General Medical Council, say they are putting plans in place to improve the situation. A number of diseases manifest differently depending on skin tone, but too little attention is given to this in training, according to Dr Joseph Hartland, who is helping to lead changes at the University of Bristol Medical School. "Historically medical education was designed and written by white middle-class men, and so there is an inherent racism in medicine that means it exists to serve white patients above all others," he said . "When patients are short of breath, for example, students are often taught to look out for a constellation of signs – including a blue tinge to the lips or fingertips – to help judge how severely ill someone is, but these signs can look different on darker skin." "Essentially we are teaching students how to recognise a life-or-death clinical sign largely in white people, and not acknowledging these differences may be dangerous," said Dr Hartland. Read full story Source: BBC News, 17 August 2020- Posted
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Event
Airway safety webinar
Patient Safety Learning posted an event in Community Calendar
The Patient Safety Movement Foundation is proud to partner with MedStar Health to offer free Continuing Education (CE) credit for this patient safety webinar. With Dr. Arthur Kanowitz, Dr. Sarah Kandil, Dr. Edwin Loftin, Dr. Anne Lyren, Dr. Kevin McQueen and Dr. Lauren Berkow. Free CE offered for physicians and nurses. This activity has been approved for AMA PRA Category 1 Credits™ and ANCC contact hours. Registration -
Event
Social Disparities Webinar (Part II)
Patient Safety Learning posted an event in Community Calendar
The Patient Safety Movement Foundation is proud to partner with MedStar Health to offer free Continuing Education (CE) credit for this patient safety webinar. With Patricia Merryweather-Arges, Dr. Ronald Wyatt, Dr. Daria Terrell, and Dr. Marcus Robinson. M Free CE offered for physicians, nurses, and pharmacists. This activity has been approved for AMA PRA Category 1 Credits™ and ANCC contact hours. Register