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Found 187 results
  1. Content Article
    This study from the THIS Institute, published in BMJ Quality and Safety, seeks to characterise features of safe care in maternity units. Hospital-based maternity units in the study displayed features that reinforce each other to optimise safety. The paper describes these features in a plain language framework, the For Us – For Unit Safety framework. Preventable harm in maternity care has devastating consequences for families, and the associated negligence claims create huge costs for the NHS. Reducing harm in maternity care is a major priority to protect families and NHS sustainability. Much work to date has focused on identifying what goes wrong in maternity care. This study takes a fresh, positive perspective and shares learning about what good looks like for safety in maternity units. The result is the For Us framework, which identifies the behaviours and practices that appear to be features of safe care in hospital-based maternity units. The framework doesn’t tell staff working in maternity units what to do. Instead it aims to aid reflection and collective learning and to target improvement efforts. It is an evidence-based framework that aims to support staff working in maternity units to reflect on what good looks like in a safe maternity unit, to identify and agree on priorities for improvement, celebrate achievements, or to make a case for increasing investment to achieve safety.
  2. Content Article
    This systematic review in BMJ Quality & Safety looks at existing research into the impact of hospital-based safety huddles. The authors found that while there are many anecdotal accounts of successful huddle programmes, there is not yet much high-quality peer-reviewed evidence regarding the effectiveness of hospital-based safety huddles. They suggest that additional rigorous research is needed to enhance collective understanding of how huddles impact patient safety and other outcomes. The review proposes a taxonomy and standardised reporting measures for future studies, to enhance comparability and evidence quality.
  3. Content Article
    The 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.
  4. Content Article
    In her latest blog, Sally Howard talks about psychological types and why understanding our preferences and how they differ to others, can be incredibly valuable. This knowledge can be used to strengthen teams, encouraging people to value diversity and work more effectively together. A particularly useful tool during these challenging times.
  5. Content Article
    A project charter is the statement of scope, objectives and people who are participating in a project.
  6. Content Article
    The Prioritisation Matrix is a structured visual tool to help you decide which improvement ideas to test first and how to focus your activity and energy. It works best in a collaborative environment and can help to build buy-in and communicate why you have chosen to test certain ideas before others. They come in many different forms, but the simplest and easiest to use is the 2 x 2 matrix. The axis of the matrix are usually labelled to enable you categorize the priority of each change idea. Usually the horizontal axis is labelled with a concept such as “effort” or “willingness to adopt”. The vertical axis is usually “impact” or “value”.
  7. Content Article
    Working with Professor Michael West, Affina OD are sharing key principles to support emerging teams and effective team working during this time of uncertainty and ambiguity. Here, he discusses 8 key principles to aid effective team working during the pandemic.
  8. Content Article
    Safety culture can be described as our: 1. Values (what is important) 2. Behaviours (the way we do things around here) 3. Beliefs (how things work). Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. NHS Education for Scotland (NES) has adapted these safety culture discussion cards (designed by EUROCONTROL) to help us to do this. Follow the link below to download the cards.
  9. Content Article
    The world today is highly complex and fast changing. New technologies become available and change the way we work, communicate and live our lives. The complex socio-economic and socio-political systems can make it difficult to anticipate the needs and requirements of tomorrow. This article discusses issues organisations have to deal with and the benefit of becoming more human-centred with help of a model aiming to influence organisations on policy level.
  10. Content Article
    In her latest blog, Claire, a critical care outreach nurse, reflects on how the 'ad hoc' team has to adapt to the new challenges the coronavirus pandemic brings. She offers insights into the challenges she and her team face and gives examples of potential solutions.
  11. Content Article
    This course, endorsed by the Intensive Care Society, provides non-ICU clinicians with rapid, targeted and effective training to support critical care delivery for COVID-19 patients. Topics include: ICU monitoring and interpretation Physiotherapy assessment and management of ICU patients Basic good ICU care Ventilation COVID and ARDS Management Vasoactive and sedative drugs. To register, contact CIRLCrehab@brunel.ac.uk
  12. Content Article
    I had been away from the hospital for a week and I was reluctant to go back in, fearful of what I would face, but I am amazed at how much has been achieved in 7 days.
  13. Content Article
    In her latest blog, Sally Howard, talks about our changing world, why transitions are so difficult and what we can do to look after each other along the way.
  14. Content Article
    The Clinical Human Factors Group have produced a useful two-page guide to key non-technical behaviours to help clinicians in this emergency. Good team work, leadership and communication – non-technical skills – will give you, patients and colleagues a better chance of staying safe.
  15. Content Article
    Miscommunications are a leading cause of serious medical errors. Communications are particularly vulnerable during handoffs. This study, published by The New England Journal of Medicine, examined the power of standardisation of processes to improve the reliability of the handoff. Testing a method called I-PASS, it engaged residents in a bundled set of activities that resulted in substantial error reductions without negative impact on their workflow.
  16. News Article
    As the world writhes in the grip of Covid-19, the epidemic has revealed something majestic and inspiring: millions of health care workers running to where they are needed, on duty, sometimes risking their own lives. In his article in the New York Times, Don Berwick says he has never before seen such an extensive, voluntary outpouring of medical help at such a global scale. Millions of health care workers are running to where they are needed, sometimes risking their lives. Intensive care doctors in Seattle connect with intensive care doctors in Wuhan to gather specific intelligence on what the Chinese have learned: details of diagnostic strategies, the physiology of the disease, approaches to managing lung failure, and more. City by city, hospitals mobilise creatively to get ready for the possible deluge: bring in retired staff members, train nurses and doctors in real time, share data on supplies around the region, set up special isolation units and scale up capacity by a factor of 100 or 1000. "We are witnessing professionalism in its highest form, skilled people putting the interests of those they serve above their own interests." Read full article Source: New York Times, 23 March 2020
  17. Content Article
    Helen is a Consultant Anaesthetist at the Oxford University Hospitals NHS Foundation Trust (OUHFT) and a Senior Clinical Research Fellow in the Nuffield Department of Clinical Neurosciences, University of Oxford. Here, Helen highlights the importance of support and training and gives an example of how the OxSTaR team are transforming staff teamworking skills and improving patient safety.
  18. Content Article
    Strengthening a safety culture necessitates interventions that simultaneously enable, enact and elaborate in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The Bundle is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture. The Patient Safety Culture "Bundle" for CEOs and Senior Leaders encompasses key concepts of safety science, implementation science, just culture, psychological safety, staff safety/health, patient and family engagement, disruptive behavior, high reliability/resilience, patient safety measurement, frontline leadership, physician leadership, staff engagement, teamwork/communication, and industry-wide standardisation/alignment.
  19. Content Article
    Author Hugh MacLeod host's this fourth episode in the ISQua Podcast series. "We do not make stuff in healthcare, we deliver care to people through people. When the relationship patterns between people are connected and healthy quality and patient safety magic happens, when they are not connected nor healthy, things fall through the cracks and patient harm and death occurs."
  20. Content Article
    This one-hour webinar considers the redesign of the patients journey and experience. Using theories that rethink the relationship between provider and ‘customer or client’, it explores co-producing better care relevant to any speciality, environment or healthcare system. This will include some practical examples learners can adapt to their own situation. By the end of the session learners will be familiar with a framework that can enable teams to work with patients to build safer, more effective and efficient care that is focused on what matters to patients and families as well as excellent performance from the team.
  21. Content Article
    This is part 5 of a series of blogs about human factors and investigations in healthcare. The theme is ‘when’ and that covers ‘when’ to investigate and ‘when’ to try any remedies or interventions your investigation data suggests might prevent the incident occurring again. As this blog can be explained by a photo and a graph, we have some time to recap the story so far and, perhaps, predict a bit of the future. 
  22. Content Article
    This podcast, is the first in a series, produced by Catalysis, about how to change organisational culture. This episode focuses on board engagement and the support a board needs to offer management during cultural transformation. 
  23. Content Article
    The Comprehensive Unit-based Safety Program (CUSP) aims to improve the culture of safety while providing frontline caregivers with the tools and support that they need to identify and tackle the hazards that threaten their patients at the unit or clinic level. Developed by Johns Hopkins safety and quality researchers, the five-step programme has been used to target a wide range of hazards, including patient falls, hospital-acquired infections, medication administration errors, specimen labeling errors and teamwork and communication breakdowns. Notably, CUSP has been used in national and international quality improvement projects that have drastically reduced hospital-acquired infections. Whether your hospital has participated in such projects or is seeking to adopt CUSP, the Armstrong Institute provides resources to help you run a successful programme.
  24. Content Article
    A problem solving tool that captures everything you need on one piece of paper. Now that sounds pretty useful.  In her latest blog, Sally Howard, Topic Lead for the hub, summarises 'A3', a problem solving tool that does exactly that. She draws on her own experience of using the tool to improve patient outcomes and provides both rich insight and practical examples to help others maximise it's potential.
  25. Content Article
    The safe management of a patient’s airway is one of the most challenging and complex tasks undertaken by a health professional - complications can result in devastating outcomes. How can anaesthetists improve safety, prevent complications, and be prepared to manage difficulties when they arise? How, in a crisis, can we ensure that human and technical resources are best utilised? This free course from Future Learn, endorsed by the Difficult Airway Society, will provide answers to these key questions and help you develop strategies to improve patient safety in your area of practice, discussing safe airway management in patient groups and multidisciplinary clinical settings.
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