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Found 187 results
  1. Content Article
    he NHS needs every one of its 1.4 million staff, but nobody is perfect every day of their career. Human factors have a huge impact on staff and patients. After witnessing poor behaviour in the workplace, co-workers are less effective and patients have worse outcomes. An unpleasant working culture also reduces camaraderie in teams and can lead to resignations. This is a vicious cycle of overwork and burnout that the NHS can’t afford. We need to nurture our workforce. In this BMJ opinion article, Scarlett McNally suggests focusing on three areas: expecting a minimum standard of behaviour at all times rather than perfectionism; identifying when intense focus is needed; and building effective teams. The minimum standard should be an expectation of “respect” at all times.
  2. Content Article
    Hospital command and control centres (CCCs) are central locations within a hospital where staff can coordinate and manage the response to emergencies, disasters and other critical events. They are also often used to track and monitor the location and status of hospital staff and resources, such as beds, equipment and supplies, in order to ensure that they are used efficiently and effectively. This blog by Sukhmeet Panesar, Chief Health Officer at Monstar Labs, acts as an introduction to CCCs in healthcare. It includes information on the different types of CCC, the benefits of CCCs and the challenges they may face.
  3. Content Article
    This editorial in BMJ Quality & Safety argues that patients' perceptions of their safety should not be dismissed when measuring healthcare safety. The authors argue that a differentiation between ‘feeling safe’, as defined through patient experience, and ‘being safe’, as defined through observation and evaluation using clinical outcomes selected by quality experts, creates a power differential and dynamic that degrades the role and value of patient experiences as valid patient safety indicators.
  4. Content Article
    This article in Social Science & Medicine aims to show how patients’ contributions to their safety in hospital are less about involvement as a deliberate intervention, and more about how patients manage their own vulnerability in their interactions with staff. The article outlines the conflict between the current focus on encouraging patients to speak up, raise queries and take ownership of their healthcare, and the relational vulnerability created by the 'sick role'—an established societal role that excuses people from their normal duties in society and entitles them to seek help. The authors highlight that supporting staff to elicit concerns from patients, and offer assurance that challenge is welcome, will be crucial in creating an environment where patients can become fully involved in own safety.
  5. Content Article
    This ethnographic qualitative study in the BMJ aimed to describe how patients are engaged with cancer decisions in the context of multidisciplinary teams (MDT) and how MDT recommendations are carried out in the context of a shared decision. The study was carried out at four head and neck cancer centres in the north of England. The authors found that the current model of MDT decision-making does not support shared decision-making, and may actively undermine it. They recommend the development of a model that allows the individual patient more input into MDT discussions, and where decisions are made on potential treatment options rather than providing a single recommendation for discussion with the patient. Deeper consideration should be given to how the MDT incorporates the patient perspective and/or delivers its discussion of options to the patient.
  6. Content Article
    This video shows CCTV footage of Bob being treated for a cardiac arrest on his way to watch a football match at the AMEX stadium in Brighton. The video could be used as a training tool to show how to start cardiopulmonary resuscitation (CPR) and how to use an automated external defibrillator (AED). The video highlights what the AED is analysing and then shocking, showing what happened to the electrical rhythm as it converts ventricular fibrillation (VF) to sinus rhythm. It also features the voice prompts from the cardiac arrest. Bob survived with a completely normal quality of life and was the seventh person (out of seven) at the AMEX stadium to have a cardiac arrest and survive with a normal quality of life. The video shows great team work and human factors interactions between the St John Ambulance volunteers who saved Bob's life, the stewarding team and paramedics.
  7. Content Article
    This article by The Health Foundation looks at an evaluation carried out by Warwick Business School of a partnership between The Virginia Mason Institute and five NHS trusts. The partnership aimed to develop a ‘lean’ culture of continuous improvement which puts patients first by developing a localised version of the Virginia Mason Production System in each of the trusts. The objective was to embed and sustain a culture of continuous improvement capability within each of these five trusts and the NHS more broadly.  Outcomes from the evaluation include insight on progress and achievements in each trust, helping them to further embed a culture of improvement capability. The learning will also enable systems leaders to maximise knowledge on how to support providers to embed and spread a culture of continuous improvement in the NHS.
  8. Content Article
    This guidance on implementing human factors in anaesthesia has been produced by the Difficult Airway Society and the Association of Anaesthetists. Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker wellbeing; implementing human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a ‘hierarchy of controls’ model and classified into design, barriers, mitigations and education and training strategies.
  9. Content Article
    In this blog for The Patients Association, Patient Safety Commissioner Henrietta Hughes looks at the importance of patient involvement in improving patient safety. She argues that patient voices should be embedded in the design and delivery of healthcare, and highlights that services and organisations need to seek feedback from patients from a wide variety of backgrounds. She also outlines why shared decision making and consent are vital to ensure patients are safe and have more control over their care and treatment.
  10. Event
    Difficult conversations - Thursday 2nd February 2023 Difficult people - Tuesday 7th February 2023 Conflict management - Wednesday 15th February 2023 This 3 day intensive training course will provide an effective guide to improving your communication skills. With each day focusing on difficult conversations, managing difficult people, and conflict and conflict resolution the course will empower you with the skills to deal with difficult issues and difficult situations within your everyday practice. Day 1 - how to deal with and manage difficult conversations. With a focus on telephone and virtual consultations with patients this masterclass focuses on dealing with difficult conversations, The event will focus on speaking to patients in distress, understanding where patient safety issues arise, and managing unhappy patients and complaints. It will discuss strategies and tools to improve communication and interactions. Day 2 - how to with difficult people. Do you have someone at work who consistently triggers you? Doesn’t listen? Takes credit for work you’ve done? Wastes your time with trivial issues? Acts like a know-it-all? Can only talk about themselves? Constantly criticises? It will discuss strategies and tools to improve communication and interactions with others. Day 3 - conflict from how to manage different types of conflict through to conflict resolution This course is aimed at all healthcare staff from frontline staff through to senior managers in dealing with conflict with colleagues, staff, clients and patients. Further information and registration
  11. Content Article
    Behind the scenes at one of the UK’s biggest hospitals as it transitions from old to new.  The Royal Liverpool University Hospital moves thousands of patients and staff to a new building. This programme documents their journey, the challenges faced and human factors involved.
  12. Content Article
    Supporting staff to speak up is essential to patient safety. The PACE communication tool is designed to help anyone in a team challenge an action or behaviour they feel is inappropriate. You can read more about PACE (probe, alert, challenge, emergency) and other communication tools on the Victorian Trauma System website via the link below.
  13. Content Article
    Teamwork is critical in delivering quality medical care, and failures in team communication and coordination are substantial contributors to medical errors. This study in JAMA Internal Medicine aimed to determine the effectiveness of increased familiarity between medical resident doctors and nurses on team performance, psychological safety and communication. The authors found that increased familiarity between nurses and residents promoted rapid improvement of nursing perception of team relationships and, over time, led to higher team performance on complex cognitive tasks in medical simulations. They argue that medical systems should consider increasing team familiarity as a way to improve doctor-nursing teamwork and patient care.
  14. Content Article
    The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Lucy Winstanley, Head of Patient Safety and Quality at West Suffolk NHS Foundation Trust, reflects on her trust's experience of being a PSIRF early adopter. Lucy talks about the benefits of PSIRF and how to make it work in practice. She highlights the need for effective collaboration between teams and the importance of engaging with patients, families and staff in new ways.
  15. Content Article
    Conversations that leaders have with their team members are the drivers of psychological safety. In this blog, Tanmay Vora looks at how to start conversations that build psychological safety in teams. He includes two infographics which highlight suggested conversation starters for team leaders and team members.
  16. Content Article
    This document by the World Health Organization (WHO) outlines an easy to follow country approach to developing or adapting an infection prevention and control guideline. It gives guidance on five steps countries can take: Prepare for action Baseline assessment Develop/adapt and execute Evaluate impact Sustain over the long term
  17. Content Article
    Since 2018, Nicola Burgess has led a team from Warwick Business School that evaluated the partnership between the English NHS and the Virginia Mason Institute in the USA. The partnership aimed to implement a systematic approach to quality improvement (QI) in five English NHS trusts and learn lessons about how to foster a culture of continuous improvement across the wider health and care system. In this blog, she summarises six key lessons from the evaluation report for health and care leaders looking to build a systematic approach to QI. Build cultural readiness as the foundation for better QI outcomes Embed QI routines and practices into everyday practice Leaders show the way and light the path for others Relationships aren’t a priority, they’re a prerequisite Holding each other to account for behaviours, not just outcomes The rule of the golden thread: not all improvement matters in the same way
  18. Content Article
    In this short blog, Patient Safety Learning sets out its initial response to the publication of the report of the independent investigation into maternity and neonatal services at the East Kent Hospitals NHS Foundation Trust.
  19. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Judy talks to us about the power of After Action Reviews (AARs) to promote learning and bring about lasting improvements in healthcare. She also discusses the opportunity that the new Patient Safety Incident Response Framework (PSIRF) offers to take a more people-focused approach to learning from patient safety incidents.
  20. Content Article
    This study in the SA Journal of Human Resource Management aimed to develop a conceptual framework that identifies the critical success factors that affect the implementation of team coaching in organisations. The results indicate that to integrate successful team coaching into any organisation, effective analysis of an organisational context is required. This includes leadership stakeholders, team effectiveness, competency of a coach and employee engagement. The study also identified constraints that may prevent successful implementation of team coaching.
  21. Content Article
    Daily huddles with staff are used to support incident reporting and learning in healthcare. This study considers a Safety-II-inspired model for safety huddles developed and implemented at the Neonatal Care Unit at a regional hospital in Sweden.
  22. Content Article
    This worksheet produced by NHS Education for Scotland is designed to be used by healthcare teams as a prompt to highlight the various system-wide factors that contribute to an issue. It aims to help teams understand how these factors relate and interact to produce different outcomes.
  23. Event
    The new NHS Patient Safety Syllabus has brought education and training to the fore to push patient safety in healthcare. Based on the syllabus this masterclass will focus on how Human Factors and Red Teams can be improve Patient Safety. Red Teams are defined as a team that is formed with the objective of subjecting an organisation’s plans, programmes, ideas and assumptions to rigorous analysis and challenge. We will look at the use of Red Teaming taken from the Ministry of Defence for supporting staff and teams faced with different problems and challenges in healthcare. For further information and to book your place visit www.healthcareconferencesuk.co.uk/conferences-masterclasses/red-teams-patient-safety or email kerry@hc-uk.org.uk hub members can receive a 20% discount. Email info@pslhub.org for discount code.
  24. Content Article
    This infographic accompanies the TeamSTEPPS for diagnosis improvement course from the US Agency for Healthcare Research and Quality (AHRQ).
  25. Content Article
    Diagnostic harm is an area of concern in healthcare quality and patient safety. A growing body of patient safety and care delivery research shows that diagnostic harm is both widespread and costly. TeamSTEPPS is an evidence-based program built on a framework composed of four teachable, learnable skills—communication, leadership, situation monitoring and mutual support. The TeamSTEPPS for Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error. On the course. teams will learn about how improved communication among all members of the team can help lead to safer, more accurate and more timely diagnosis in all healthcare settings. The course can be delivered virtually, in a classroom setting or as individual self-paced learning modules. Additional resources for trainees include: Team assessment tool for improving diagnosis Case study of the diagnostic journey of Mr. Kane Reflective practice tool Postcourse knowledge assessment
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