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Showing results for tags 'Just Culture'.
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Content Article
Recommendations from the study Just Culture: define an agreed vision of what Just Culture means to the Trust. Investigations: introduce incident management familiarisation training. Learning Culture: increase face-to-face communication of outcomes of investigations and incident review. Investigators: establish an incident investigation team to improve the timeliness and consistency of investigations and the communication and implementation of outcomes.- Posted
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Content Article
The World Health Organization states that unsafe care is one of the top ten leading causes of death and disability worldwide, with the NHS estimating that there are around 11,000 avoidable deaths annually due to safety concerns. However, despite a range of international and national initiatives aimed at reducing avoidable harm, it remains a persistent, wide-scale problem. A key reason for this is the implementation gap, the difference between what we know improves patient safety and what is done in practice. In this report Patient Safety Learning highlights six specific policy areas where- Posted
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Commissioned by the Department of Health and Social Care (DHSC) in February 2020, the Independent Investigation into East Kent Maternity services published its report last month highlighting patient safety failings in maternity and neonatal care services from 2009–2020 at two hospitals: Queen Elizabeth The Queen Mother Hospital at Margate and the William Harvey Hospital in Ashford. This is another devastating report detailing cases of serious avoidable harm and preventable deaths in the NHS, stating that it found that: “... those responsible for the services too often provided clinic- Posted
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A report published by the Harmed Patients Alliance, “Signpost to Nowhere?” the case for funded independent advocacy, advice and information for patients and families following patient safety incidents” shines a bright light on this neglected issue and offers a way forward. The report points out the irony of the NHS focus on “just” culture when it is prepared to abandon the people it has harmed in this way. It suggests that the NHS owes a “moral duty of care ” to attend to the needs it creates for people affected by avoidable harm in the NHS to support their wellbeing, trust in the NHS and- Posted
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The report highlights six key themes, identified from discussions and good practice ideas, to help develop a safety culture: Leadership Continuous learning and improvement Measurement and systems Teamwork and communication Psychological safety Inclusion, diversity and narrowing healthcare inequalities It also provides a brief overview of three case studies, with links to full versions of these on the FutureNHS Collaboration Platform.- Posted
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Event
Just Culture and incident investigation
Patient Safety Learning posted a calendar event in Community Calendar
untilThis virtual seminar from the Clinical Human Factors Group will be looking at Just Culture and incident investigation and will feature two of the authors, Jan Davies and Carmella Steinke, of the new book 'Fatal Solution' , a book which describes "how a healthcare system used tragedy to transform itself and redefine Just Culture". In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put t- Posted
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Event
Error and systems-based solutions to patient safety including Human Factors
Patient Safety Learning posted a calendar event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on errors and designing system-based solutions to improve patient saf- Posted
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Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
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- Duty of Candour
- Just Culture
- Leadership
- Organisational culture
- Organisational development
- Organisational learning
- Safety culture
- Transformation
- Speaking up
- Transparency
- Whistleblowing
- Change management
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- Hierarchy
- Staff support
- 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- Posted
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Tagged with:
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- 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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Event
untilThis webinar from the Irish Health Services Executive National Quality and Patient Safety Directorate will enable you to: understand what restorative just culture means in practice appreciate how you can apply restorative just culture to your local context learn the benefits of restorative just culture for patients, staff and business hear top tips for applying restorative just culture Register for the webinar- Posted
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Content Article
"Thank you for the opportunity to speak today and support the system leadership being shown by the PSA. My name is Helen Hughes, and I am the Chief Executive of Patient Safety Learning, a charity and an independent voice for system wide change. We seek to improve patient safety through our policy, influencing and campaigning, as well as developing and promoting ‘how to’ resources such as the hub, our free learning platform for patient safety, and our recently launched organisational standards for patient safety. At the heart of our approach is a commitment to listen to, learn from a- Posted
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Content Article
Nuffield Trust: Safety culture in the NHS (25 August 2022)
Mark Hughes posted an article in Culture
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- Staff safety
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