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Found 210 results
  1. Content Article
    Fear of retaliation by leaders or colleagues can prevent staff from reporting adverse events, unsafe conditions, or near misses. This article presents strategies to improve just culture in the perioperative environment, which is prone to hierarchical structure. Strategies include creating an accessible reporting system, implementation of a "good catch" programme, and leadership support for staff who submit reports.
  2. Content Article
    Imagine an organisational culture of trust, learning and accountability. In the wake of an incident, a restorative just culture asks: ‘who are hurt, what do they need, and whose obligation is it to meet that need?’ It doesn’t dwell on questions of rules and violations and consequences. Instead, it gathers those affected by an incident and collaboratively addresses the harms and needs created by it, in a way that is respectful to all parties. It holds people accountable by looking forward to what must be done to repair, to heal and to prevent. This film documents the amazing transformation in one organisation —Mersey Care, an NHS mental health trust in the UK. Only a few years ago, blame was common and trust was scarce. Dismissals were frequent: caregivers were suspended without a clear idea of what they might have done wrong. Mersey Care’s journey toward a just and learning culture has repaired and reinvigorated relationships between staff, leaders and service users. It has enhanced people’s engagement, joint ownership and sense of responsibility. It has taken the organization to a place where hurt doesn’t get met with more hurt, but with healing.
  3. Content Article
    The stressful nature of the medical profession is a known trigger for aggression or abuse among healthcare staff. Interprofessional incivility, defined as low-intensity negative interactions with ambiguous or unclear intent to harm, has recently become an occupational concern in healthcare. While incivility in nursing has been widely investigated, its prevalence among physicians and its impact on patient care are poorly understood. This review summarises current understanding of the effects of interprofessional incivility on medical performance, service and patient care.
  4. Event
    Restorative practice - learning culture, how do you create a culture where people feel able to speak up and be listened to. Freedom to speak up, enabling a culture where people feel able to speak up, governance, board assurance, Culture and Good Governance - OFLOG dept launched in July which will look at governance in local authorities. There’s been an incident in your organization. People are impacted. You need to do something. How do you avoid blame, and how do you start learning and improving? This session will explore the principles and theory behind a just and learning culture and give you some insights into how this can be implemented. Alongside an international thought leader on this subject we will hear from an NHS organisation’s experience of developing and sustaining their approach to this. This session will help you understand how your teams/services/organisations can create cultures that foster learning when things don't go as expected. People will leave with an understanding of a just and learning culture alongside insights around implementation in their own organisations. Register
  5. Content Article
    "Our #health system in the UK is in a mess. It has failed to modernise (by this I mean to become fully accountable to #patients and the public, and truly patient-led). Instead, the system has become more and more hierarchical, bureaucratic and crony ridden, mostly as a result of constant meddling and pointless reorganisations instigated by politicians. All political parties in government for the past 30 years have had a hand in this decline." This is my view? What is yours? A new Inquiry gives us all an opportunity to have our say. I am proud to have worked in and for the NHS for most of my working life; proud to have been trained in the #NHS and proud of the work being carried out by clinical teams today. Great work which has benefited patients, often not because of the leadership but despite of the leadership. I'm retired so I can say what I like. If I were working and said anything even vaguely like criticism, however constructive it was, I would be out of a job and my career would be blighted for life. I'm speaking from experience here, unfortunately. I urge everyone to respond to the consultation (link below). In your response think forensically and write it as a statement of truth. Acknowledge the successes and areas that have delivered safe and effective services. If you are being critical give examples and say if it is an opinion or back up what you say with evidence. If we work together across boundaries we can develop a truly patient-led NHS.
  6. Content Article
    In the intricate world of healthcare, where patient safety is paramount, the ability to speak up is a crucial component of a culture of safety. However, the complexities surrounding voicing concerns or challenging the status quo in a healthcare environment can be extremely daunting. Speaking up to those who are respected, who are perceived as more powerful or more influential is not easy. Even asking questions, let alone questioning others can create tension or even risk relationships. We are too often silenced by others or are purposefully silent ourselves because it is the easier thing to do. In this blog, Suzette Woodward discusses the barriers to speaking up and what we can do.
  7. Content Article
    In this infographic, the Patient Safety Commissioner for England, Dr Henrietta Hughes, sets out her strategy for supporting the development of a new culture for the health system centred on listening to patients.
  8. Content Article
    Northumbria University is exploring the experiences of NHS Trusts taking steps to move towards a Restorative Just Culture to develop and share an informative ‘how to’ guide. They would like to hear your views if you are you an NHS Trust who has attended the Northumbria University and Mersey Care NHS FT programme: Principles and Practices of Restorative Just Culture and have implemented, or attempted to implement, restorative just culture. It will take approximately 45 minutes of your time to take part in an online interview/focus group. If you are interested in participating or have any questions please contact bl.rjc@northumbria.ac.uk. Download the attachment below for more information.
  9. Content Article
    In this blog, Scott Ellner, a general surgeon from the US, describes the case of a surgeon colleague who unintentionally harmed a patient, Sarah, during surgery. Sarah ended up in the surgical intensive care unit from septic shock due to a missed bowel injury. Her recovery from what should have been a straightforward procedure was long and complicated. Scott recalls how the surgeon was shocked by the way Sarah's husband responded to him when he explained what had happened—instead of an anger and blame, Sarah's husband expressed compassion for the doctor and reiterated his trust in him. Scott highlights the importance of creating a Just Culture in healthcare systems and outlines challenges to this in the current climate, referring to the case of nurse RaDonda Vaught. He also outlines the impact patient safety incidents and medical errors can have on healthcare professionals, calling on the healthcare community to embrace shared humanity. All of us come with imperfections, vulnerabilities and the capacity for healing and growth.
  10. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Lucy and Rebecca talk to us about their experience as Patient Safety Incident Response Framework (PSIRF) early adopters. They discuss how PSIRF puts patients at the centre of incident investigations, and the challenges and opportunities they have faced in implementing PSIRF at West Suffolk NHS Foundation Trust.
  11. Content Article
    Drawing on his research and practice, Steven Shorrock explores the various barriers that we face when trying to make sense of Just Culture, inviting readers to refl ect on the intricate nature of justice and safety in our complex world
  12. Content Article
    Healthcare is starting to embrace a shift towards Just Culture. In England, the new Patient Safety Incident Response Framework (PSIRF) prioritises respect, compassion, and systemic improvements. The potential benefits of this, and other initiatives, are significant, as Suzette Woodward reports
  13. Content Article
    This issue of Hindsight is on the theme of Just Culture…Revisited. The articles reflect Just Culture at the corporate and judicial levels from the perspectives of personal experience, professional practice, theory, research, regulation, and law. You will find a diverse set of articles from a diverse set of authors in the context of aviation, maritime, rail and healthcare. What is ‘just’? How should we conceptualise Just Culture? How should we design and implement regulations, policies and protocols relating to Just Culture? What gets in the way of Just Culture? In this issue, leading voices from the ground and air share perspectives on these questions.
  14. Content Article
    Healthcare often uses the experience of aviation to set its patient safety agenda, and the benefits of a ‘safety management system’ (SMS) are currently being espoused, possibly because the former chief investigator for HSIB, Keith Conradi, had an aviation background. So, what does an SMS look like and would it be beneficial in healthcare? In this blog, Norman MacLeod discusses aviation's SMS, its many component parts, the four pillars of an SMS, just culture and its role in healthcare.
  15. Content Article
    Despite years of calls for adoption of a Just Culture, it is evident that taking this concept from paper to practice has been slower than expected. Many have cited the subpar application of the Just Culture framework and, recently, questions have been raised regarding how the Just Culture framework is perceived by those impacted by harm, including patients, family members, and staff. Though this framework is one tool that can be used to guide inquiry after harm events, its use, independent of active efforts toward restoration of relationships with patients, families, and staff, could compromise engagement and therefore learning. A lack of focus on restoring the trust of those affected by harm in parallel with the event investigation introduces a risk of further compounding the harm for all involved. Those involved in safety work at NHS England have recognized the need to apply a systems mindset within a concerted effort toward more compassionate engagement for optimal learning and improvement. In response, they have included compassionate engagement and involvement of those affected by patient safety incidents as a foundational pillar in the NHS England Patient Safety Incident Response Framework.
  16. Content Article
    ‘Compassionate communication, meaningful engagement’ is a handbook for all NHS staff which aims to improve collaboration with patients, their families and carers following a patient safety event. Developed with NHS Trusts across England in partnership with Making Families Count, the guide includes principles of compassionate engagement, roles and responsibilities of healthcare professionals, and information about the processes following an incident. It also brings together a range of signposting information and resources for families and staff.
  17. Content Article
    In this opinion piece for the BMJ, Partha Kar, NHS England National Specialty Advisor for Diabetes, shares his observations on why leaders fail to speak out on things that clearly aren't good for patient care. He identifies five key reasons: Keeping the job Fear Rhetoric about 'the bigger picture' The idea that 'I'll be rewarded' Genuine belief that the issue isn't real Partha highlights that speaking up about issues needs to become the norm if we are to see a culture shift in healthcare. Leaders need to be at the forefront of this, using their privilege to bring about change.
  18. Content Article
    Improving patient safety culture – a practical guide, developed in association with the AHSN Network, brings together existing approaches to shifting safety culture as a resource to support teams to understand their safety culture and how to approach improving it. It is intended to be used across health and social care to support everyone to improve the safety culture in their organisation or area. The guide specifically focuses on: teamwork communication just culture psychological safety promoting diversity and inclusive behaviours civility. Teams should use the guide to find a way to start to improve their culture that is most relevant to their local context. It will support teams to explore different approaches to help them to create windows into their daily work to help them to understand their local safety culture.
  19. News Article
    Press release: 7 April 2022 Today the charity Patient Safety Learning has published a new report, ‘Mind the implementation gap: The persistence of avoidable harm in the NHS'. The report is an evidence-based summary of the failures over decades to translate learning into action and safety improvement. It highlights that avoidable unsafe care kills and harms thousands of people each year in the UK and costs the NHS billions of pounds for additional treatment, support, and compensatory costs. The report highlights how we fail to learn lessons from incidents of unsafe care and are not taking the action needed to prevent harm recurring. The report focuses on six sources of patient safety insights and recommendations, ranging from inquiry reports into patient safety scandals, such as the recent Ockenden report into maternal and neonatal harm at Shrewsbury and Telford Hospital, to the findings of Coroner’s Prevention of Future Deaths reports. It calls on the Government, parliamentarians, and NHS leaders to take action to address the underlying causes of avoidable harm in healthcare and proposes recommendations in each policy area. Patient Safety Learning is calling for system-wide action in healthcare to transform our approach to learning and safety improvement. Helen Hughes, Chief Executive of Patient Safety Learning, said: “Today’s report highlights the all too frequent examples of where healthcare organisations fail to learn lessons from incidents of unsafe care and not taking the action needed to prevent future harm. Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations.” “This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learned’ and ‘action will be taken to prevent future avoidable harm to others’. The healthcare system needs to understand and address the barriers for implementing recommendations, not just continually repeat them. Hope is not a strategy.” This report has been published as part of the Safety for All Campaign, which calls for improvements in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all. The campaign is supported by Patient Safety Learning and the Safer Healthcare and Biosafety Network. Notes to editors: Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. Safer Healthcare and Biosafety Network an independent forum focused on improving healthcare worker and patient safety and has been in existence more than 20 years. It is made up of clinicians, professional associations, trades unions and employers, manufacturers and government agencies with the shared objective to improve occupational health and safety and patient safety in healthcare. COVID-19 pandemic has provided a stark reminder of the vital role healthcare professionals play in providing care to those in our society who need it most and this was recognized in the WHO Patient Safety Day in September 2020: only when healthcare workers are safe can patients be safe. In 2020, the Network launched a campaign called ‘Safety for All’ to improve practice in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all.
  20. News Article
    Patient safety and nursing groups around the country are lamenting the guilty verdict in the trial of a former nurse in Tennessee, USA. The moment nurse RaDonda Vaught realised she had given a patient the wrong medication, she rushed to the doctors working to revive 75-year-old Charlene Murphey and told them what she had done. Within hours, she made a full report of her mistake to the Vanderbilt University Medical Center. Murphey died the next day, on 27 December 2017. On Friday, a jury found Vaught guilty of criminally negligent homicide and gross neglect. That verdict — and the fact that Vaught was charged at all — worries patient safety and nursing groups that have worked for years to move hospital culture away from cover-ups, blame and punishment, and toward the honest reporting of mistakes. The move to a “Just Culture" seeks to improve safety by analyzing human errors and making systemic changes to prevent their recurrence. And that can't happen if providers think they could go to prison, they say. “The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent,” the American Nurses Association said. “Health care delivery is highly complex. It is inevitable that mistakes will happen. ... It is completely unrealistic to think otherwise.” Read full story Source: The Independent, 31 March 2022
  21. Content Article
    Healthcare relies on high levels of human performance; however, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. This narrative review in the journal Anaesthesia aims to describe what is known about human factors in anaesthesia to date.
  22. Content Article
    This poster produced by researchers at Warwick Medical School summarises a qualitative research project that examined attitudes and behaviours related to patient safety culture at a single West Midlands Trust. The study's objective was to gain an understanding of staff’s views regarding the culture within the Trust and of their attitudes and behaviours when reviewing clinical incidents and mortality and morbidity. The poster was a winner at the HSJ Patient Safety Congress 2022 in the category 'A just culture for learning and change'. Read the full research paper.
  23. Content Article
    This article in BMJ Open Quality aimed to improve patient safety by examining the organisational and individual factors that contribute to adverse events, enabling corrective action so that errors are not repeated. Using interviews and observations of Trust meetings at a single Hospital Trust in the Midlands, England, this qualitative study: analysed whether the attitudes and behaviours of clinicians and managers are aligned with a Just Culture. identified barriers and enablers to an organisation adopting a Just Culture. The study found evidence of a fair incident management process within the Trust; however, there was no agreed vision of a Just Culture and the majority of the staff were unfamiliar with the term. Negative perspectives relating to clinical incidents and their management persist among staff with many having concerns about being the subject of an investigation and doubts about whether they drive improvement.
  24. Content Article
    This editorial by Barbara Fain, Chief Executive of the Betsy Lehman Center in Massachusetts, highlights the need to focus on system safety and moving away from a culture of individual blame, in order to improve patient safety. Referring to the case of nurse RaDonda Vaught who was convicted of negligent homicide for a medication error at a Tennessee hospital, Barbara looks at research that demonstrates that people generally believe the best way to reduce the likelihood of medical errors is by choosing the right doctor, and argues that this cultural belief played into Vaught's conviction. She highlights the need to use evidence-based strategies to communicate with healthcare professionals and the public about the wider picture of patient safety and systems thinking.
  25. Content Article
    A recently published report highlights the shortcomings in care provided by the NHS. Peter Walsh, Joanne Hughes and James Titcombe emphasise how millions could be saved if people were empowered early on to have their needs met without the need to turn to litigation
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