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Errors are the result of actions that fail to generate the intended outcomes. They are categorised according to the cognitive processes involved towards the goal of the action and according to whether they are related to planning or execution of the activity. This article in SKYbrary discusses the types of human error.- Posted
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A Brighton GP surgery is under threat despite providing excellent services and strong links to the local community. This decision flies in the face of the proven 'social value' being delivered and potentially puts patients at risk. The reasons are presented in this excellent article which exposes the continued 'race to the bottom' due to an apparently unnecessary tendering exercise, a decision made behind closed doors and a failure to consult. Quote from Polly Toynbee's article in the Guardian: "Here’s the puzzle. Andrew Lansley’s calamitous system that opened the NHS to “any willing provider” to compete for contracts was supposedly swept away in 2022, replaced with ICBs that strove for cooperation across all NHS and social services in England. Yet some ICBs still apply the old competitive impulse to NHS services, even though they now have an obligation to ensure that tenders help to reduce inequalities."- Posted
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If you have up to an hour to spare, these 'micro credentials' are great for topping up your learning. The Chartered Institute of Ergonomics & Human Factors (CIEHF) online bitesize modules will offer you short, focused and easily digestible content. Delivered through CIEHF's online learning platform, they'll provide the flexibility to learn at your own pace, to your schedule and from wherever you choose. Whether you're a professional seeking to improve workplace ergonomics or a curious learner eager to understand how humans interact with their surroundings, these modules are designed to inspire you by providing real-world examples, case studies and best practice that can be applied across many sectors. You'll get insights into identifying and addressing human factors challenges, ultimately contributing to improved safety, efficiency and overall wellbeing.- Posted
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Orthopaedic surgeon Sunny Deo has spent three decades diagnosing and treating knee joint issues. In this blog, Sunny argues that the healthcare community needs to take a more nuanced approach to diagnosis and decision making so that it can provide patients with safer, more appropriate treatment options. He reflects on why medicine prefers simple answers and looks at how this affects patient care. He goes on to explore how better data collection and the use of artificial intelligence (AI) could provide a more accurate picture of complexity and allow treatment options to be better tailored to individual patients’ needs. "To know the patient that has the disease is more important than to know the disease that the patient has." William Osler, father of modern medicine, 1849-1919. Diagnosis is the process of identifying the nature of an illness or other problem by examining the symptoms and objective findings from investigations. In modern medicine, it is a key focal point of the assessment and management of all patients. A huge amount of clinical medicine training is focused on the art and science of obtaining a diagnosis, and this focus continues into medical practice. The ease of getting to a diagnosis ranges from the glaringly obvious, the so-called ‘spot diagnosis’, through to cases that are very difficult to solve. In between these extremes there is a range from delayed to missed to incorrect diagnosis. The aim of doctors over the centuries has been to work out diagnoses from patients’ symptoms, presenting features (clinical signs) and, in the past century or so, from the evidence of clinical investigations. Quite often, symptoms, signs and investigations produce consistent patterns, and it is these patterns that are taught to medical and other healthcare professionals. This is how diagnoses and outcomes are portrayed in television series or films—just think back to the last episode of Casualty or Grey’s Anatomy you watched. It's also how things often appear in internet searches and on websites and social media. Seeking simple answers to complex questions However, the reality is different. When a patient is sitting in front of me, what I hear and observe may not exactly be what the textbooks, evidence or research tells me I should be seeing. But because we are wired and trained to recognise patterns, we tend to look for diagnoses and solutions that fit within the well-worn narrative. What if the pattern doesn’t fit the actual diagnosis? There are classic presentations for nearly every condition, and these are what you tend to find at the start of a Google search or when using NHS Choices. The expectation of typical symptoms sometimes means we ignore what we might see as annoying variance, superfluous detail or the patient embellishing the truth. This discordance then causes tension with a very basic trait of humans: when we’re faced with a difficult problem, we still seek the simplest solution. This is an evolutionary feature hardwired into us to optimise survival chances. It means we often believe there is a truth to be found that will provide us with a definite answer. From this answer we will come to the best, and ideally only, ‘correct’ solution. Patients who don’t fit the set patterns of diagnosis may then run into trouble when we offer them what is considered to be the ideal treatment. This is an important problem in clinical thinking, language and practice. As a medical community, we tend to create oversimplified approaches based on research that looks for binary answers to complex questions. This research evidence may be based on a small, highly selective ‘typical’ patient cohort, but its findings and conclusions are then translated on to the entire population. This approach results in poor patient outcomes and experience for a small but significant proportion of patients. Pathways designed for ideal diagnoses can cause harm to patients Over my 30 years as an orthopaedic surgeon, 15 as a knee specialist, I have seen that the assessment and treatment of any given condition isn't quite as predictable as we would like it to be. While many patients fit the pattern we are expecting, some do not. I would empirically put the proportion at 60:40, but some unpublished research we did a decade ago suggested the proportion of truly ‘typical’ case presentations for a common condition is much lower. For example, we found that in the case of suspected meniscal tear, this diagnosis actually applied to only 33% of patients with a variety of other diagnoses accounting for the rest. It gets worse when large organisations start to lump patients into a category by condition in a ‘one diagnosis fits all’ strategy. When this approach is taken, there are winners and losers. The winners are those patients whose condition very closely matches the classic presentation of a given condition in isolation. Let’s take the example of knee osteoarthritis—patients with the ‘right type’ of symptoms, physical signs and x-ray changes are generally more likely to do well. Their recovery is more likely to sit within the knowledge base of treating the condition that has evolved over the past half-century. In contrast, patients whose symptoms and test results fall outside of this category may be less likely to do well or recover in the predicted timeframe. This also applies to patients with additional diagnoses or conditions, often termed comorbidities, which may interact, usually in a bad way, with the condition at hand. Failure to consider other diagnoses, either by over-focus on one condition causing wilful ignorance, inattention or lack of attention, may lead to unexpected poor outcomes from a given treatment. It may also mean that the symptoms from the condition that the patient presents with are worse than expected. This doesn’t mean that they won't gain any benefit from a particular treatment, but the risks and potential outcomes may not be communicated adequately by the patient’s healthcare team, if at all. For example, for patients with painful knee osteoarthritis, the current diagnosis to treatment logic runs like this: Knee osteoarthritis is a painful condition. Total knee replacement surgery is a validated safe procedure with significant improvements in quality of life. Other treatment options do not produce as much positive therapeutic benefit compared to total knee replacement surgery. Therefore, total knee replacement surgery is the only treatment for painful knee osteoarthritis. However, there are patients for whom knee replacement surgery is not a safe or practical option, and these patients may benefit from alternative treatments that are not currently offered as they are seen as providing limited benefit. This may be because the participants in trials undertaken over the years had varying diagnoses, meaning that true comparisons of alternative options may have had additional interacting diagnoses or failed to account for differing severity. Understanding the spectrum of complexity As healthcare professionals, we have a duty to diagnose patients as accurately as possible. In orthopaedics, if treatments go wrong or are poorly undertaken, it may lead to prolonged or permanent pain or disability, and we obviously want to avoid this as much as possible. Incomplete identification and documentation of all relevant symptoms and health conditions can potentially lead to an increased risk of treatment failure and complications. Our priority should be to identify these diagnoses or diagnostic clusters as accurately as possible. I think these are basic principles we need to apply to create better systems and improved care for as many patients as possible. In my view, there are grades of ‘atypical patients’ and I have devoted the past decade to trying to demonstrate this, with surprisingly stiff resistance from peer-reviewed journals and funding organisations. I have tried to move away from lumping all patients into a single category. I have done some research on seemingly straightforward soft tissue problems and osteoarthritis in the knee. My initial analysis suggests that we need to collect more detailed and accurate data, rather than simplifying data into minimum datasets. This is where AI can really come into its own, not as a diagnostic tool initially, but as a powerful aid to unlocking and interpreting some of the diagnostic interactions that create problems for patients. However, the use of AI does need to be undertaken with extreme care and consideration, and this isn’t always happening currently. To offer healthcare that is truly person-centred, we need to look beyond our well-worn simple answers and solutions. By using better data and new machine learning tools to understand the nuances of each person’s condition and how it relates to their wider health, we can offer treatment options that are safer, kinder and more cost-effective. Share your views We would love to hear your views on the issues highlighted in Sunny’s blog Are you a clinician who would like to share your experiences? Do these challenges resonate with you? Or are you a patient who has experienced complications because of poor, missed or inadequate diagnosis? Add your comment below (you will need to be a hub member and signed in) or contact us at [email protected] and we can share your story anonymously. Related content on the hub: Using data to improve decision making and person-centred care in surgery: An interview with Sunny Deo and Matthew Bacon Diagnostic errors and delays: why quality investigations are key- Posted
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My experience of speaking up as a healthcare assistant in a care home
Anonymous posted an article in By health and care staff
A frank account from a healthcare assistant on the bullying she experienced after raising concerns at the care home she worked in. I was employed as a healthcare assistant in a care home, where I worked for about three months. During this time, I found out that patient safety and quality of care were undermined by healthcare assistants, and the management and the nurses did not seem to realise it. Examples included: Carers were given a box of gloves each and they were expected to use them for up to two weeks. When asked for more gloves, the manager would check the last time they took a box of gloves and would question what they had done with the last ones they collected. In order to save the gloves, carers used one pair of gloves to deliver personal care to three to five residents before changing them. They would take the rest of the gloves home and bring them back to work in the next shift. Genital care was totally neglected. Residents’ genitals were not cleaned. I spoke to a nurse in another unit about this and all she said was she thought it was being done. When carrying out personal care to one lady, I found dried faeces wrapped in her pubic hair which took me a good number of minutes to clean. When I finally finished doing it, the lady pointed at her private part and said to me “it can breathe now” and when I asked why, she said “because it has been washed”. Infection control. One of the problems was that there was never any soap in the bathrooms and places where there were wash hand basins. So, after personal care, especially after caring for residents who had opened their bowels, we could only wash our hands with clear water. Hand sanitiser dispensers were hanging empty with no sanitising gel, so no opportunity for either visitors or staff to sanitise their hands whilst in the care home. Healthcare assistants apparently had no clue about catheter care, even those working at the nursing unit where there were a few residents that had catheters. I never saw any of them doing catheter care and one day when I was doing it, my colleague was really frightened, held my hand back and said I was going to pull the catheter out. Most of the times when residents opened their bowels, carers would either clean it very shallowly, or they would only take out the soiled pads and replace them with clean ones without cleaning the area at all. As such, when you took over the shift, during the first checks you would think that a resident had opened bowels but find out that the pad was dry and clean at that moment, but the faeces on it and on their skin was dried up. Oral and nail care was another issue. Carers never did oral care, and those who bothered to document would say “resident denied oral care”. Some of the residents’ beds were not functioning, especially in the nursing unit where most of the residents were bed-ridden. This meant that healthcare assistant staff had to bend and strain their backs each time they were giving personal care, which would lead to backaches. After trying to share my concerns on the above issues with three nurses to no avail, I was only left with the choice of talking to the management. I wrote a letter of observation, accompanied by some recommendations. I ended my letter by letting the management know that I was ready to discuss my concerns with them at any time. They did not call me up for any discussion. A change in behaviour... A few days later I started noticing a change of behaviour from all staff towards me. Most of them did not talk to me, many times I found out that people were whispering things about me as when they saw me approaching them they would stop talking. One unit reported that I was very slow, and I was never assigned to work there anymore. People ignored me when I tried to join in a conversation. Each time I was working, nobody would let me do personal care. I was only allowed to work as an assistant to fellow healthcare assistants. In some rooms where I went in first and started doing personal care, they would tell me that I was taking too much time. My opinion on anything did not count. One day when I came to work, there was a small problem which needed to be fixed between one of the nurses and myself, but she refused to listen to me and insisted that I should go back home. I went home as she had asked, and the next day I called and told the manager that I was sent home last night. He started blaming me based on what the nurse had told him, which was not true, without listening to my own side of the story. I insisted that he should call a meeting where he could listen to both of us, because what the nurse had said was untrue. His response to me was that I would need a reference from him so I should be careful about the way I did things. However, he finally accepted and we agreed on a date for the meeting. But when it came to the day of the meeting, the nurse was not there. I explained myself to my manager, in the presence of the secretary. His response to the letter I wrote with my concerns in was that he appreciated it, but he thought that the care home was not the right place for me, and that he thought that I was too qualified for the job. He suggested that everybody felt threatened with my presence. I told him that that it sounded to me like he wanted to remove me from my job; a job which I very much wanted to do. When I came back for the next shift, I discovered that my shift had been cancelled and I had been replaced by someone else. I spoke to a senior carer who called my manager and he told me that he was not expecting me to come to work because of what had happened the other night. I went back home. The next day he called and told me that after due consideration, he had decided to extend my probation time to a further three months, and that I should compose myself, come to work and do only what I was expected to do. Psychologically tortured As I continued working, things got worse each day. I experienced colleagues laughing at me, talking about me, not talking to me, ignoring me; the list could go on and on. I was psychologically tortured. I developed a violent headache. Each time I thought I was going back to work I felt sick, got palpitations, felt so hot as if I had fever, at times shivering, with painful nerves. I kept asking myself whether I was wrong to have done what I did. I did a lot of self-counselling and told myself that I was going to stay at the workplace if I was not dismissed. This was because I was planning to write more letters. I had only highlighted a few of the many issues in my first letter. My hope was that one day someone was going to understand me and things would improve. One night I stopped a colleague from putting a pad on a resident she had not cleaned properly. I cleaned the resident and did vaginal and catheter care, before putting on the pad. There was another resident who was very wet, from their pyjamas to the bedding; my colleague wanted us to only change the pad and let the resident lay with the wet clothes on the wet bed “since they were going to wash her in the morning anyway”. This was the 1am check, and I argued that I could not imagine her being able to fall asleep in that condition. We ended up changing the resident’s pyjamas and putting a towel and an extra pad on the bed to make her feel comfortable. Forced into resigning My colleague became angry with me. I was surprised because I had done nothing wrong. There was altercation and she confronted me. I couldn’t tell anyone as no one would believe me. I felt excluded and alone and the only thing that came to my mind was that I should resign. When I finished work in the morning I went and told my manager that I was resigning. He told me that I was expected to give two weeks’ notice and that I should write my resignation letter that day, which I did. He told me it was rather unfortunate that it hadn’t worked out for me in the care home… Did I do the right thing? What would you do?- Posted
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This poster forms part of the resources to support the implementation of the Safe Learning Environment Charter. NHS England Safe Learning Environment Charter (SLEC) has 10 priorities, they are: Respect and feeling valued Positive identity Wellbeing Raising concerns & speaking up Placement induction Communication Flexibility Supervision Teaching and learning needs Time and space for learning. The SLEC priorities and solutions present clearly to education and placement providers, assessors, supervisors and learners, as well as others working in the health and care system, what must underpin the culture of our learning environments. The SLEC is written for the use of education and placement providers, assessors, supervisors and learners, however it must be actioned by everyone, everywhere, every day and the behaviours and principles embedded into our culture. Equality, diversity and inclusion (EDI) and patient safety is the golden thread that runs through the SLEC Charter.- Posted
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Wrist-based wearables in the US have been FDA approved for atrial fibrillation (AF) detection. However, the health behaviour impact of false AF alerts from wearables on older patients at high risk for AF are not known. In this work, the authors analysed data from the Pulsewatch (NCT03761394) study, which randomised patients with history of stroke or transient ischemic attack to wear a patch monitor and a smartwatch linked to a smartphone running the Pulsewatch application vs to only the cardiac patch monitor over 14 days. At baseline and 14 days, participants completed validated instruments to assess for anxiety, patient activation, perceived mental and physical health, chronic symptom management self-efficacy, and medicine adherence. The authors used linear regression to examine associations between false AF alerts with change in patient-reported outcomes. Receipt of false AF alerts was related to a dose-dependent decline in self-perceived physical health and levels of disease self-management. The authors developed a novel convolutional denoising autoencoder (CDA) to remove motion and noise artifacts in photoplethysmography (PPG) segments to optimize AF detection, which substantially reduced the number of false alerts. A promising approach to avoid negative impact of false alerts is to employ artificial intelligence driven algorithms to improve accuracy.- Posted
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In a dynamic healthcare environment, patient safety is crucial. A "Conscious Actions Reduce Errors" (C.A.R.E) approach is needed to safeguard safety and reduce medical errors. The dual process theory highlights two thinking modes: intuitive (fast, automatic) and analytical (slow, deliberate). Intuitive thinking, though quick and often effective, can lead to cognitive biases like anchoring and availability heuristics. A C.A.R.E approach incorporating tools like the TWED checklist (Threat, What if I'm wrong? What else?, Evidence, Dispositional factors) and Shisa Kanko (Japanese method of pointing and calling) can help to improve decision-making and action precision in clinical settings.- Posted
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News Article
A doctor has admitted to inappropriately messaging a vulnerable teen who he met in a hospital, and later went on to have a sexual relationship with. Dr Cian Hughes, who lists himself as research scientist at Google on LinkedIn, began privately messaging the 13-year-old while she was a patient at Bristol Royal Hospital for Children. Dr Hughes, who was a 23-year-old medical student at the time, had been present during surgery on the young patient and later approached her about a research project, a tribunal heard. Dr Hughes used his private email address to email the girl copies of her X-rays, and this began a chain of communication that ultimately led to a sexual relationship between them when the girl was 17, the tribunal heard. The General Medical Council (GMC) brought a case against the doctor saying that he used his professional position to pursue an inappropriate relationship with the vulnerable patient. Read full story Source: The Independent, 16 January 2025- Posted
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Interprofessional communication and teamwork is critical to patient safety. First-year medical and nursing residents participated in team engagement sessions focused on collaboration and safety behaviours through socialisation, team communication, and engagement skills. Sessions consisted of a pre-recorded scenario of a safety event resulting in a patient's death followed by a facilitated debrief. Escalation of care, SBAR (situation, background, assessment, recommendation), and “ask a question, make a request, voice a concern” were identified as the top 3 safety/communication techniques that could have changed the outcome of the simulated scenario. Approximately two-thirds of participants perceived lack of confidence and fear of giving the wrong information as barriers to safety/communication techniques. -
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The current consultation by the Department of Health and Social Care, ‘Leading the NHS: proposals to regulate NHS managers’ defines professional standards as “…the values, behaviours and competencies that managers will be expected to demonstrate.” In this blog, Lesley Parkinson, Executive Director at Restorative Thinking, and author of 'Restorative Practice at Work', explains what restorative and relational practice is and why this needs to be explicitly written into the professional standards being developed to improve relationships and accountability. There is currently not a set of recognised professional standards for NHS managers and I understand that NHS England is in the process of developing these. My hope is that restorative and relational practice will be included. This consists of a set of principles, processes and skills that guide our thinking, language and behaviours, and help us to continually build and improve our relationship skills. The graphic below gives a little more detail about what restorative and relational practice offers: If these behaviours and processes can be coherently and explicitly written into the professional standards being developed, they will go some way to improving relationships and accountability. This will have a positive impact on patient safety, as there will be less likelihood of people carrying grudges, feeling that things aren’t fair and other emotional distractions that prevent us from giving our full attention to the patients in front of us. There is already some guidance around workplace behaviours in the NHS; ‘compassionate leadership’ and ‘civility and respect’ spring to mind. Restorative and relational practice adds the detail of processes and language to deliberately foster equality of voice and respectfully challenge each other when we see, hear or feel something that isn’t right; this could be the way someone speaks to us or something we observe taking place that looks wrong or unsafe. Approaching someone in order to challenge them is a key relationship skill that needs deliberate and specific attention. If our approach is accusatory, we will likely meet a defensive or argumentative response; this interaction could damage a relationship immediately and in the long term. Restorative and relational practice helps us to navigate this tricky territory so that we learn how to respectfully challenge each other: to pause judgement; invite perspectives; discuss feelings and expectations; end with a solution in which there’s clear accountability and agreement. The Restorative Thinking team is currently delivering workshops with NHS trusts to develop these particular skills, but I’m afraid there’s no quick fix. The language and processes we use are based on a group of psychological and behavioural sciences and it’s key that we understand and grasp these before putting the theory into practice. New research from the Imperial College Business School shows how leaders can make constructive challenge not just possible but an integral part of a thriving organisational culture. In terms of the current Department of Health and Social Care consultation, I’ve observed the most effective regulation is done within teams and departments, person to person. It's clear that too many leaders, managers and staff lack the relationship skills to regulate each other; this is what needs to be addressed so that all NHS staff (whatever their role) can give their full attention to patient care and patient safety. The good news is that the Restorative Thinking team is developing learning options: podcasts, videos and paper resources, to help facilitate this ‘relationships education’ and we are building a self-guided learning page on our website to be launched in 2025. We already offer a short e-learning course and we've started to publish freely available podcasts on this theme. We are also partnering with the organisation AQUA to help NHS organisations to design and deliver safer care for patients by including restorative and relational practice into staff inductions, staff training, organisational development and Board development sessions.- Posted
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Junior doctors joining Emergency Departments (EDs) are required to rapidly acquire new knowledge and skills, but there is little research describing how this process can be facilitated. This study looked at what would make ED formal induction and early socialisation more effective. New junior doctors identified that early socialisation should facilitate patient safety and a safe learning space, with much of this process dependent on consultant interactions rather than formal induction. Clear themes around helpful and unhelpful consultant support and supervision were identified. Consultants who acknowledged their own fallibility and maintained approachability produced a safe learning environment, while consultants who lacked interest in their juniors, publicly humiliated them or disregarded the junior doctors’ suggestions were seen as unhelpful and unconstructive. Effective socialisation, consistent with previous literature, was identified as critical. Junior doctors see consultant behaviours and interactions as key to creating a safe learning space.- Posted
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This exploratory investigation by the Healthcare Services Safety Investigations Body (HSSIB) considered the potential of conducting a full investigation into the patient safety risks associated with sexual safety. As part of this work, HSSIB engaged with 20 different stakeholder organisations including national organisations, regulators, universities, royal colleges and professional organisations, national patient advocacy organisations, and independent activist groups. HSSIB found there were many ongoing and new initiatives, such as the NHS sexual safety in healthcare organisational charter, that would take time to develop, embed and reach a mature state to allow evaluation. It concluded that a full HSSIB investigation would therefore offer limited value at this time. As part of this exploratory investigation, HSSIB made the following safety observations: Health and care organisations can improve patient safety by capturing the impacts, events and circumstances where sexual safety incidents have affected the provision of safe care. This would help organisations to understand and assess the risks posed to patient safety. Health and care organisations can reduce duplication of effort within sexual safety improvement work by increasing co-ordination and collaboration. This should accelerate and enhance the potential improvements across organisations. There is an opportunity for health and care organisations to share learning around implementing the 10 principles of NHS England’s ‘Sexual safety in healthcare – organisational charter’. This would enhance shared knowledge, understanding and mechanisms for embedding the principles.- Posted
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This roadmap sets out the government’s ambition to transition away from all avoidable single-use medical technology (medtech) products towards a functioning circular system by 2045 that maximises reuse, remanufacture and recycling. Circularity in medtech means designing, procuring and processing medical products in a way that enables them to be reused, remanufactured or recycled, preserving their value for as long as possible. The benefits of a circular economy in the health sector are vast and increasingly well-understood, but are rarely put into practice and are difficult to scale. Unlocking these benefits across the UK medtech sector will bring many opportunities for innovation and growth, while improving patient care and value for money and supporting the transition to a net zero NHS. This document sets out a plan of 30 actions to deliver our 2045 vision, which will involve: driving positive behavioural change exploring new commercial incentives to provide circular medtech creating new standards to enable innovative products and services planning the decontamination and recycling infrastructure of the future establishing new collaborations to accelerate the emergence of transformative science.- Posted
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Hospital warned over safety and ‘undermining behaviour’
Patient Safety Learning posted a news article in News
Regulators are carrying out “enhanced monitoring” of clinical radiology services at a major London hospital, after concerns about safety and “undermining behaviour”. The General Medical Council introduced the special measures on the department at Northwick Park Hospital in Harrow last month, it has emerged, after concerns were raised in the regulator’s annual survey by higher specialty trainees. Enhanced monitoring is used when a department or hospital has failed to improve after concerns have been raised locally, and where the GMC feels the quality of training could affect patient safety or junior doctors’ ability to progress. In relation to Northwick Park’s clinical radiology, issues highlighted included staff behaviour, whether there is a “supportive environment”, trainee safety, clinical supervision out of hours, educational supervision, and resources for trainers. GMC medical director and director for education and standards Professor Colin Melville said it was concerned about “the quality of training in the department and undermining behaviours”. He added: “We’ll continue to work closely with NHS England London to make sure an improvement plan is implemented. We will check that progress is being made to make sure trainees and registrants are working in a safe, supportive, and sustainable training environment.” Read full story (paywalled) Source: HSJ, 23 October 2024- Posted
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NHS England has launched this new policy and supporting assurance framework for integrated care boards and trusts to adopt and adapt, ensuring that any member of staff who has experienced inappropriate and/or harmful sexual behaviours at work is supported by their employer. It will help staff to: understand their rights and responsibilities recognise and report sexual misconduct at work get advice and support. An overview of the policy is also available. Alongside the policy is a new e-learning resource, designed to equip people working and learning in the NHS with the knowledge and skills to recognise and respond to sexual misconduct.- Posted
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Identifying and standardising how healthcare systems and regulators measure violence against health care workers can help predict, prevent, and address such incidents. The Institute for Healthcare Improvement (IHI) Innovation team recently completed a 90-day research cycle to draft a framework that health systems might use to create reliable prediction and response systems to reduce physical violence and improve safety of the healthcare workforce. It completed a literature scan of existing approaches and frameworks and conducted key informant and expert interviews with approximately thirty experts at 19 healthcare organisations. Figure 1. Keeping the Health Care Workforce Safe from Violence Driver Diagram (IHI, 2023).- Posted
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The NHS long-term plan sets out a national vision for leadership that is both compassionate and diverse. This King's Fund live online event explored the evidence base and what practical and behavioural changes are required now and over the next ten years to achieve that cultural change.- Posted
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Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
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- Organisational development
- Organisational learning
- Safety culture
- Transformation
- Speaking up
- Transparency
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- Benchmarking
- Clinical governance
- Accountability
Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views?- Posted
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- Behaviour
- Resources / Organisational management
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(and 24 more)
Tagged with:
- Behaviour
- Resources / Organisational management
- Communication problems
- Decision making
- Organisation / service factors
- System safety
- User centred design
- Culture of fear
- Duty of Candour
- Just Culture
- Leadership
- Organisational culture
- Organisational development
- Organisational learning
- Safety culture
- Transformation
- Speaking up
- Transparency
- Whistleblowing
- Change management
- Collaboration
- Hierarchy
- Staff support
- Benchmarking
- Clinical governance
- Accountability
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Content Article
This research examined sexual misconduct occurring in surgery in the UK, so that more informed and targeted actions can be taken to make healthcare safer for staff and patients. A survey assessed individuals’ experiences with being sexually harassed, sexually assaulted, and raped by work colleagues. Individuals were also asked whether they had seen this happen to others at work. Compared with men, women were much more likely to have seen sexual misconduct happening to others, and to have it happen to them. Individuals were also asked whether they thought healthcare-related organizations were handling issues of sexual misconduct adequately; most did not think they were. The General Medical Council (GMC) received the lowest evaluations. The results of this study have implications for all stakeholders, including patients. Sexual misconduct was commonly experienced by respondents, representing a serious issue for the profession. There is a widespread lack of faith in the UK organizations responsible for dealing with this issue. Those organizations have a duty to protect the workforce, and to protect patients. Further reading: Breaking the silence: Addressing sexual misconduct in healthcare Calling out the sexist and misogynist culture within healthcare: a blog by Dr Chelcie Jewitt, co-founder of the Surviving in Scrubs campaign GMC's Good medical practice 2024- Posted
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- Womens health
- Organisational culture
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Content Article
The Family Oops and Burns First Aid eBook
Kristina Stiles posted an article in Recommended books and literature
'The Family Oops and Burns First Aid' is a free children's book written by Kristina Stiles, beautifully illustrated by Jill Latter, created to support children and their families learning about burns prevention and first aid principles together. The book describes an accident prone family who are not burns aware, who have to go to school to learn about burn safety and first aid principles within the home. The book is aimed at KS1 children and their families, and is available as hard copy book by request from Children's Burns Trust and also as an audio/video book via YouTube.- Posted
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- Patient / family involvement
- Health education
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Content Article
It has become fashionable to purge the term ‘error’ from the safety narrative. Instead, we would rather talk about the ‘stuff that goes right’. Unfortunately, this view overlooks the fact that we depend on errors to get things right in the first place. We need to distinguish between an error as an outcome and error as feedback, writes Norman MacLeod in this blog for the hub. In an increasingly litigious world, intolerant of failure, error has become inextricable linked with fault and blame. Here, error is considered in hindsight by agents in positions of power or with specific agendas. Something happened and someone must pay. Clichés such as ‘error is natural’ or ‘no one intends to make a mistake’ carry little weight. Unfortunately, this interpretation of ‘error’ feeds into debates in the safety domain but simply rejecting the term misses the point. To understand the importance of error we need to reflect on the nature of the world. Imagine a small pile of sand on a table. As you add more grains of sand, the cone will build, maintaining its shape until, eventually, the next single grain will trigger a cascade. Sand will slip down the side of the cone until a new shape is stabilised. And, so, the process goes on. The cone is stable under most circumstances but just a single grain of sand can trigger a transition to a new stable state. The world, then, exists in a state of self-organised criticality. This is important. If the world was too stable, it would not be able to respond to change. Instability, then, is an adaptive property. It also means that work must contend with this inherent instability. We need to be constantly adapting to events as we encounter them, which might not be how we anticipated them at the outset. It is this mismatch between ‘expected’ and ‘actual’ that is one source of error. But there is a more fundamental process that gives rise to error. All action flows from decisions made by a brain encased in bone. It has no direct access to the outside world. The brain acts like a Bayesian probability engine. The brain creates a set of expectations about the nature of the world, and these are compared with sensory inputs. Any discrepancies – errors – are resolved until our perceived reality meets a threshold. Our investment in establishing ‘reality’ is just enough to support whatever action is needed to achieve our goals. This last statement presupposes that all action is goal directed. Error, in this context, is feedback from the world about the correlation between our actions and our progress towards our goal. In fact, error is information that reduces uncertainty. In this sense, error allows us to fine-tune our actions. Studies of airline pilot performance reveal that about a third of errors committed by crew go unnoticed. They are seen by the trained observer, but not by the perpetrators, and barely 1% of these errors have any sort of impact on the operation of the aircraft. This suggests two things: first, in aviation at least, the operation is resilient and can cope with error; second, the consequence of error does not seem to impinge upon the crew’s understanding of what is happening to the extent that they need to take any action. However, when an error does come to the attention of the crew, a response is needed. Again, studies show that a significant proportion of detected errors are simply ignored by crew. Fewer than half require a positive intervention. It is fashionable to talk about error ‘management’. In fact, crew do not ‘manage’ errors: instead, they respond to the new set of circumstances created by the error. Error is the trace you leave behind, like the wake of a ship. You play what is in front of you and don’t look back. But what about the ‘things that go right’? Here is a game you can play. Imagine you are watching someone in the workplace. How do you know things are going right? Probably, it’s because you haven’t seen anything going wrong. We are designed to detect ‘wrong’ because that is what will save our lives. It’s an evolutionary thing. We are blind to ‘right’ because that is simply our expectations – the brain’s prediction – being met. That said, have you ever been impressed by something you have seen at work? Again, this is our prediction not being met, but in a surprising way rather than a negative way. Surprises, like failures, are learning opportunities. Both allow us to refine our internal representations of tasks, leading to better goal specification and richer action sequences directed at attaining that goal. Error, then, is not only good but also essential. The original meaning of ‘error’ was to wander. It is not the wandering that really matters but the path people were trying to follow in the first place. Key take away points: 1. After a process failure, the goal is to explain the gap between planned and actual. Culpability comes a distant second. 2. Most responses to adverse events merely shift the point of failure. The work will be no less variable and the role of error will not change. 3. If you really need a 'Just Culture' policy it suggests that the people with power do not understand error.- Posted
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- Human error
- Organisational learning
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Content Article
This blog (attached below) explores how far the nature of our relationships at work have an impact on patient safety. Lesley Parkinson – the executive director of Restorative Thinking, a social enterprise working to introduce and embed restorative and relational practice in the NHS and across public sector organisations – explores how six restorative practice habits add value in multiple teams and scenarios. You can also order Lesley's book Restorative Practice at Work Six habits for improving relationships in healthcare settings.- Posted
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- Restorative Justice
- Safety culture
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Content Article
The Professional Standards Authority (PSA) commissioned this research to help inform a consistent and appropriate approach by the regulators and registers towards the various types of discrimination in health and care. The research was undertaken to help PSA understand better the views of the public and service users on the following key questions: What constitutes discriminatory behaviour in the context of health and care? What impact discriminatory behaviour may have on both public safety and confidence? Through looking at these two areas, the research also drew out views from participants on how health and care professional regulators should respond to different types of discriminatory behaviour. Key findings The notion that all patients should be provided the same standard of care and respect was at the heart of what the public and patients expected from health and care professionals. Within this, equality and diversity were understood as both providing a standard of service that was universal (the same for everyone), as well as ensuring inclusion so different needs were recognised and met. Discriminatory behaviours were therefore defined as those where some patients were denied the same standard of care or respect or they were subject to practices that were not inclusive of their particular needs. As part of the research, some participants shared experiences of health and care professionals’ behaviours they felt were discriminatory and linked to their protected characteristics. Examples of such behaviours included: Verbal remarks which patients felt were disparaging. Making assumptions and being judgemental about patients. Not listening to patients. Not meeting additional needs of patients, for example, communication needs. In a small number of cases, patients also reported what they perceived as more serious discriminatory behaviours, including aggressive behaviour in mental health hospitals, and harassment of Muslim women wearing a veil. Further discussions prompted by using a range of scenarios involving potentially discriminatory behaviours revealed key factors the public and patients considered when assessing whether behaviours were discriminatory. These included: Intent – whether a behaviour was intentionally discriminatory or stemmed from a lack of knowledge and understanding. Outcomes for patients and how vulnerable the patient was – whether the impact was serious and negative for patients, which would be exacerbated if a patient was deemed vulnerable. Frequency – whether a particular behaviour was an isolated incident or part of a pattern of behaviour. Most felt that discriminatory behaviours could potentially cause significant harm to patients, as well as undermine their confidence in health and care professionals and services more broadly. Such behaviours were perceived to potentially impact on: Patients’ mental health and wellbeing, as direct experiences of discriminatory behaviours could make patients feel uncomfortable, anxious, confused, embarrassed, or distressed, depending on the severity and kind of behaviour in question; • Patients’ physical health and wellbeing, as many thought they would attempt to avoid professionals who behaved in this way, which could make accessing health services more difficult. Patients’ confidence in health and care professionals, as discriminatory behaviours were perceived to undermine core values and professionalism expected in health and care. Patients’ safety when using health and care services, as many felt that witnessing such behaviours would make them question whether these professionals may harbour other prejudices that could impact on their treatment too.- Posted
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- Health inequalities
- Health Disparities
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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.- Posted
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- Human factors
- Organisational culture
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