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Found 187 results
  1. Community Post
    Great blog in Learn from Martin on who should be in an investigation team - the expertise of the team, their roles and responsibilities. Do you agree?
  2. Content Article
    This is part three of a series about the investigation process and human factors in healthcare. Part one looked at the why we investigate an ‘incident’. It concluded that there is only one reason to investigate – and that’s to stop the error occurring again. The idea that human factors is a science – done by science types was introduced. That facts are best collected by a minimum of two investigators. Pictures being our friend, and the cognitive interview concept was introduced. This part focuses on ‘Who’ should investigate and deals with the experience and expertise of the team, their roles and responsibilities in the light of the facts they will collect.  This blog is aimed at individual trusts and organisations rather than regulators/national bodies, etc.
  3. Content Article
    ‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery.
  4. Content Article
    Effective communication is critical for patient safety. One potential threat to communication in the operating room is incivility. Although examined in other industries, little has been done to examine how incivility impacts the ability to deliver safe care in a crisis. In this US based study, the authors sought to determine how incivility influenced anaesthesiology resident performance during a standardised simulation scenario of occult haemorrhage.
  5. Community Post
    Talking with John Holt, PS Mnager at Birmingham and Solihull CCG today. Would it be helpful to set up a CCG PS Mansger community?
  6. Content Article
    Paul Batalden has defined quality improvement as: “the combined and unceasing efforts of everyone – healthcare professionals, patients and their families, researchers, payers, planners and educators – to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning)”. Quality improvement (QI) goes beyond traditional management, target setting and policy making. QI methodology is best applied when tackling complex adaptive problems – where the problem isn’t completely understood and where the answer isn’t known – for example, how to reduce frequency of violence on inpatient mental health wards. QI utilises the subject matter expertise of people closest to the issue – staff and service users – to identify potential solutions and test them. East London NHS Foundation Trust (ELFT) is a provider of mental health and community services, to a population of approximately 1.5 million people, mainly across East London, Bedfordshire and Luton.
  7. Content Article
    Clinicians who are unable to cope with their emotions after a medical error or adverse event are suffering in silence. These healthcare providers are often told to take care of the next patient without an opportunity to discuss the details of the event or share how this has affected them personally and professionally. While patients and families are the first victims of such events, we refer to the healthcare providers who are involved as the second victims.
  8. Content Article
    Objective: To determine whether patients/family members interviewed could identify at least one contributing factor for the event they experienced. Secondary objectives included understanding the way patients/family members became aware of adverse events, the types of contributing factors patients/family members identified for different types of adverse events, and recommendations provided by patients/family members to address the contributing factors. Originally published in Health Services Research.
  9. Content Article
    High quality handovers are essential for safe healthcare and are used in many clinical situations. Miscommunication during handovers can lead to unnecessary diagnostic delays, patients not receiving required treatment, and medication errors. Miscommunication is one of the leading causes for adverse events resulting in death or serious injury to patients. The process of handovers can be improved, and the aim of this article is to provide practical guidance for clinicians on how to do this better.
  10. Content Article
    "Among many other opportunities created by the launch of the World Alliance for Patient Safety is the hope that one day the learning from the inadvertent death of a patient in a hospital in one country could save the lives of many others around the world."  In his paper, Sir Liam Donaldson (Chair of the WHO World Alliance for Patient Safety at the time) talks about the importance of global collaboration for patient safety.
  11. Content Article
    Effective teamwork is critical to successful outcomes in pediatric cardiac surgery. Unfortunately, lapses in professional performance and conduct by those who treat paediatric cardiac patients pose threats to quality and safety. One hallmark of a profession is self regulation. Therefore, healthcare leaders need specific means for identifying and addressing those lapses and indicators of unsafe systems or individuals. This article from Pichert et al. describes an initial “near miss” event involving a paediatric cardiac surgeon. While fictional, the case represents a composite of events involving several paediatric cardiac surgeons who practice at different medical centers throughout the US.
  12. Content Article
    Implementation of the Swabsafe™ management system at the The Princess Grace Hospital following a never event.
  13. Content Article
    Mark Lomax, CEO at Patient Experience Platform, talks about the value of disruptive healthcare innovations and how to identify the 'disruption killers' and the champions within an organisation.
  14. Content Article
    The D5 ward was visited as part of the University Hospital Southampton's Care Quality Commission (CQC) inspection and was verbally fed back to have a different ‘feel’ to other wards in the trust. It was felt that the ward was chaotic and lacked clear leadership, on top of this there were some safety concerns raised by both the inspection team and from adverse event reports that were being submitted by the ward.
  15. Content Article
    Malcolm's Story, produced by Karen Harrison, Tissue Viability Nurse at Hull University Teaching Hospitals NHS Trust, is a video of Malcolm, his daughter and his wife sharing their experiences of Malcolm being a patient in our Trust and developing a hospital acquired pressure ulcer while in our care. 
  16. Content Article
    Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Patient Safety Team's values became a golden thread to improve patient safety by 'Sharing How We Care' – a monthly patient safety newsletter and annual conference.
  17. Content Article
    It is now accepted that healthy cultures in NHS organisations are crucial to ensuring the delivery of high-quality patient care. The Kings Fund developed a tool to help organisations assess their culture, identifying the ways in which it is working well, as well as the areas that need to change.
  18. Content Article
    What links the Mercedes Formula One team with Google? What links Team Sky and the aviation industry? What connects James Dyson and David Beckham? According to this book, they are all Black Box Thinkers. Written by Matthew Syed, Black Box Thinking is a new approach to high performance, a means of finding an edge in a complex and fast-changing world. 
  19. Content Article
    This leaflet by NHS Employers (Wales) explains what bullying in the workplace is, how it can affect people and what to do about it.
  20. Content Article
    The NHS Long Term Plan highlighted several safety issues that need to be addressed: the fear of blame and retribution which curtails reporting and learning, lack of staff understanding of patient safety matters and workforce issues. This short article summarises what I have learnt about how After Action Review (AAR) can directly address the first two of these and indirectly impact on the third. 
  21. Community Post
    Here's a recent interesting blog post on leadership under pressure https://www.med-led.co.uk/2019/08/19/under-pressure/
  22. 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.
  23. Content Article
    Second part of a blog by Mark Hellaby on how simulation can be used to support some of the emerging patient safety concepts.
  24. Content Article
    The Royal College of Emergency Medicine has developed The Safety Toolkit which aims to describe the structures, processes and skills required for a ‘safe’ department. There are resources identified within each section to stimulate, provoke and challenge, as well as guide personal development. There are overlapping references and differing perspectives but the vision is of a resource for change and development.
  25. Community Post
    Root case analysis has its detractors but can still bring value to understanding deep-seated problems that affect the safety of care. Does anyone have a checklist of elements of an effective TRAINING strategy to bring staff on board with the process? Not how to do an RCA, but to bring a team to the skill competencies they need to do RCA? I'd appreciate hearing your experiences. Please tell your tales!
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