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Found 142 results
  1. Content Article
    The widespread implementation of CPOE thoughout the US has benefited clinicians and patients, but it also vividly illustrates the risks and unintended consequences of digitising a fundamental healthcare process, this paper published in PSNet explains how and why.
  2. News Article
    The Doctors’ Association UK has compiled stories from 602 frontline doctors which expose a startling culture of bullying and overwork in the NHS. The stories include: a pregnant doctor who fainted after being forced to stand up for 15 hours straight and being denied water. The junior doctor was subsequently shouted at in front of colleagues and patients on regaining consciousness and told it was her choice to be pregnant and that ‘no allowances would be made’. a doctor who told us that a junior doctor hung themselves in a cupboard whilst on shift and was not found for 3 days as no-one had looked for them. His junior doctor colleagues were not allowed to talk about his suicide and it was all ‘hushed up’. a doctor who was denied a change of clothes into scrubs after having a miscarriage at work despite her trousers being soaked in blood. Full press release
  3. Content Article
    This report, Hearing and Responding to the Stories of Survivors of Surgical Mesh, describes how restorative justice approaches were used to uncover the harms and needs created by surgical mesh use in New Zealand. The actions that consumers and healthcare stakeholders indicated would restore well-being, trust and safe healthcare in New Zealand are included. Skilled facilitators used restorative practices to create a safe space for consumers and health professionals to tell their stories. The same approach supported collaboration between multiple agencies so they could act for repair and prevention. The team that co-created the project includes academics, consumers, facilitators and New Zealand's Chief Clinical Officers. Formal research will evaluate the project next year and consider findings in the context of resilient healthcare systems
  4. Content Article
    I work in, both, the work imagined and prescribed, but practice in the world of work done. It’s interesting working in both worlds and has made me ask these questions: Why this happens? What are the consequences? How can we manage this disconnect? Real-life scenario What happened? A patient on a ward needs a nasogastric tube (NGT) for feeding and giving medication due to an impaired swallow following head and neck surgery. The nurse prints off the policy for placing an NGT from the Trust's infonet. The nurse inserts the NGT and checks the policy on how to test if it is in the correct position. The tube could be in the stomach (the right place) or it could be placed in the lungs (not a great place for medicines and feed to go!). The nurse calls the nurse in charge for support. It’s been a long time since she has placed an NGT and she wants to check she iss doing the right thing. The senior nurse arrives, before the feed is commenced. The senior nurse notices that the policy that the nurse is using is out of date. Checking the position of NGTs had changed. The senior nurse prints out the updated policy – NGT was in the correct position. This was a near miss event. So what? If an NGT is in the lung and you give medication and liquid feed there is a high chance the patient would contract fatal pneumonia at worst or a protracted stay on the intensive care unit on a ventilator at best. In both these cases, it would need to be declared to the regulators as they are classed as serious incidents. What next? This incident was one of many near misses that were collected over four shifts. This incident was discussed with the Deputy Chief of safety within that Trust. His first reaction was: "When was this? We had a Datix last year of the same incident – why has this happened again and why don’t I know?" It was true, there were a few similar incidents last year and an action plan was put in place to mitigate another incident like this happening again. All the old policies were to be removed from the infonet and replaced with the updated versions. Not only this, the Trust was now moving towards a web-based search facility that enables the clinician to have all the updated evidence for policies, antibiotic therapies, prompt charts, documentation and prescribing advice. The guide would be updated and the old policies would automatically be replaced, thus mitigating clinicians using out of date policies and procedures. The document management system was put in place to ensure it is easier to do the right thing. So, if this forcible function was in place, how did this incident happen again? Not all staff know about the new document system. Some nurses think this search facility is for doctors only. Nurses are prohibited to use their mobile phones on the ward. Clinicians not always able to get to a computer. It takes too long to update when opening the browser – therefore people are using it offline. The final point is an interesting one. Making it easy to do the right thing is one of a number of aspects that a safe system is comprised of; however, if part of that system i.e. the Wifi is not set up to support the change, that system is at risk of a ‘work around’. Work arounds are what healthcare staff do to enable them to get through that shift without immediate detriment to themselves or the patient, make swift complex decisions easily and to ‘tick the box’. Time is a precious commodity, especially when you are a frontline worker. We know the document management system will have the updated policy; we wait for the download. We wait. We wait a bit longer. Eventually it loads. Remembering it takes a long time, we save it and use it ‘offline’ for future access. By using the guide offline makes it quick and easy. We are using Trust policy; however, that policy may now be out of date. So what? Implementation of this online guide was made to make our lives easier and safer for patients and ourselves. Due to an oversight of how clinicians ‘actually’ use and interact with this change in the work environment, it could have an adverse outcome for patients. How would the safety team know this was happening? Near misses seldom get reported. Chance meetings in corridors, chance conversations overheard, a reliance on staff that may know the answer – if we ‘fixed’ the problem for that near miss, why should we report it? No harm came to the patient after all. We have a good culture of reporting in the Trust; however, our safety team are overwhelmed with incidents to investigate. The current system is set up to investigate when harm has happened rather than seeking out ways to prevent harm. I’m part of the problem, so I can be part of the solution? I would welcome any support on this. Does anyone have any solutions or strategies in place where frontline staff are involved in the reporting of near miss events and are part of the solution to mitigate them?
  5. Content Article
    In this remarkable documentary, you can follow Kym Bancroft and Sidney Dekker in one organisation's (Urban Utilities) successful adoption and implementation of Safety Differently principles.
  6. Content Article
    This toolkit is organised around three pillars –teamwork and communication for perinatal safety, perinatal safety strategies, and in situ simulations. Each pillar contains a Powerpoint® slide set, accompanying facilitator guide and tools to support change at the unit level. It also includes the experiences of five labour and delivery units that successfully implemented the programme.
  7. Content Article
    Colour is a hallmark of Autumn across the US. A more spectacular set of colours, in a variety of shapes and sizes, paint the sky at daybreak every October in New Mexico. The Albuquerque International Balloon Fiesta is the largest gathering of its kind. In 2019, its 48th year, the fiesta hosted 550 hot air balloons, 650 pilots and entertained close to 900,000 visitors. The event holds a place on the bucket lists of travellers around the world. It is hard to describe the feeling of glee standing amid a mass ascension until you’ve been there amongst the early morning crowds. You might think it’s all fun, funnel cakes and floating but—like any aviation activity—ballooning entails risk. Make no mistake, the balloonists and their teams, the organisers, law enforcement, and even participants play a role in the safety of the event. Before sunrise each day, the “dawn patrol” of 8–10 hot air balloonists lift off. These experienced pilots gage the safety of the sky prior to the authorities giving the signal for the assent to begin. Only after that, does the wave after wave of multiple balloons unpack, gear up, inflate and take off from the field. Crews mull about, patiently navigating their designated space amongst onlookers and their cameras to get ready for flight. They implement standard procedures to safely gear-up for flight. Healthcare, too, prepares teams for complex situations to ensure safety through standardisation and practice. The US healthcare accreditation agency, the Joint Commission, shared insights on reducing maternal harm due to postpartum haemorrhaging that summarises best practices centered on readiness, recognition, response and reporting to support systems learning. Stanford Medicine in California recently held a series of “dress rehearsals” prior to opening a new hospital. The test of the space gave clinicians, administrators and patient advisors a chance to make sure conditions were right for a safe opening day. The fiesta organisers also deploy tactics to learn from what doesn’t go well. They use technology to gather input from crews and the public to identify areas for improvement. Traffic into the 360-acre launch site creates ineffective and potentially dangerous situations given the swell of people arriving in town. Attendees almost double the size of the city for the 10-day event. Public input gathered online helped planners to redesign this year’s park and ride shuttle system after it failed in 2018 to reliably get people to the festival. Hospitals also use information technology to learn how to improve the safety of the care experience. Researchers in Washington State developed a 4-step model built on inpatient experiences with undesirable events. They used patient and family knowledge to design informatics solutions that engage patients as contributors to safety. The model supports raising awareness of problems, encouraging prevention actions, managing emotional harms and reducing barriers to reporting .A rare situation stalled the festival this year: fog. Yes, fog is not something New Mexican’s encounter often but it shut down opening day morning—none of the balloonists could take off. This unique occurrence would have been all the more problematic had teams not heeded safety advice in this less-than-ideal situation. Practices and protocols keep patients safe too but only if they are followed. A unique set of circumstances led to the death of a patient awaiting care in a Pennsylvania emergency department. Protocols weren’t followed limiting situation awareness, communication and process completion. Balls were dropped and the results were tragic. Complex systems can manifest unintended consequences from strategies designed to protect people. Balloon fiesta has its share of mishaps. Pilots end up in the Rio Grande, drift into powerlines, bones get broken and, rarely, lives are lost. The expert crews mean well but failures happen. A nurse in Tennessee who made a medication mistake that resulted in patient death was charged criminally. While lawmakers may feel this is a just approach, it is a threat to healthcare transparency. A series of incidents involving misdiagnosis of child abuse is raising concerns in the US. While specialised paediatricians can readily identify patient conditions that indicate abuse, sometimes those judgements are made in error. The decisions made to protect children instead accuse innocent parents or family members of harm. The safe flight of those families then tumbles to the ground. The pace is back to normal in Albuquerque. Balloons still float above us in the morning and afternoon—'tis the season. They brighten the clear blue skies with the Sandia mountains as a backdrop. But you can bet that what did go wrong this year will be folded into the event planning so all that participate in the 2020 festival will be as safe as possible.
  8. Content Article
    Working with colleagues across the health service community, they are focusing on these key areas: Safer Care through NEWS2 (National Early Warning Score) Emergency Department Safety Checklist Emergency Laparotomy Collaborative Structured Mortality Reviews.
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