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Found 48 results
  1. Content Article
    Key findings 59.7% think their organisation treats staff who are involved in an error, near miss or incident fairly. This is a 1 percentage point improvement since 2018 (58.3%) and continues a positive trend since 2015 (52.2%). 71.1% think their organisation takes action to ensure that reported errors, near misses or incidents do not happen again. 73.8 think their organisation acts on concerns raised by patients / service users (2018: 73.4%). 61.1% gives them feedback about changes made in response to reported errors, near misses and incidents (q17d) This is a 1 percentage point improvement since 2018 (60.0%) and continues an upward trend since 2015 (54.1%). 71.7% would feel secure raising concerns about unsafe clinical practice. This is a 1 percentage point increase since 2018 (70.7%). 59.8% were confident that their organisation would address their concern .This has continued an upward trend since 2017 (57.6%).
  2. News Article
    Today the results of the National NHS Staff Survey 2019 are out. This is of the largest workforce surveys in the world with 300 NHS organisations taking part, including 229 trusts. It asks NHS staff in England about their experiences of working for their respective NHS organisations. The results found that 59.7% of staff think their organisation treats staff who are involved in an error, near miss or incident fairly. While an improvement on recent years (52.2% in 2015) work is needed to move from a blame culture to one that encourages and supports incident reporting. It also found that 73.8% of staff think their organisation acts on concerns raised by patients/service users. It is vital that patients are engaged for patient safety during their care and there is clear research evidence that active patient engagement helps to reduce unsafe care. Patient Safety Learning has recently launched a new blog series on the hub to develop our understanding of the needs of patients, families and staff when things go wrong and looking at how these needs may be best met.
  3. News Article
    The ghosts of medical errors haunt Dr. Peter Pronovost. Two deaths, both caused by mistakes. First, his father’s, who died as the result of a cancer misdiagnosis. Then a little girl, a burn victim who succumbed to infection and diagnostic missteps at the hospital where Pronovost worked early in his career. Those deaths led Pronovost to pursue a medical career dedicated to patient safety, and to create the medical checklist he has become known for worldwide. Now, he’s implementing his second act, at University Hospitals in the USA, as its Chief Transformation Officer, a job he has held since late 2018. His goal: To transform a $4 billion health care system by reducing shortcomings in medical care and increasing the quality of treatment. The challenge fits Pronovost, says one of his former Johns Hopkins University professors, Dr. Albert Wu. “He’s one of the few people for whom the title might be appropriate, because his work has led to significant changes and innovations in how we deliver health care in the United States. “He’s a once-in-a-generation guy.” Read full story Source: Cleveland.com, 9 February 2020
  4. Content Article
    Better use of data is essential to speed up diagnosis, research new treatments, plan better NHS services and monitor the safety of drugs. And yet, more than two thirds of the population feel they don’t know how patient data is used in the NHS. These animations have been developed in partnership with charities, patients and clinicians. Find out why and how patient data is used.
  5. Content Article
    In this video, Senior Paediatric Intensivist, Adrian Plunkett from Birmingham Childrens Hospital UK, discusses positive reporting (as opposed to incident reporting) in improving morale and outcome in sepsis.
  6. Content Article
    We know from our own experiences and those of others that patient safety fears are growing daily across the NHS and social care. Staff shortages and burnout are all taking their toll on patient satisfaction, safety and standards of care. I had the pleasure of joining a webinar arranged by the Health Foundation last week where the National Director of Improvement for NHS England and NHS Improvement, Hugh McCaughey, outlined the up and coming improvement framework for the NHS. A good framework provides a skeleton on which to build. His presentation included the importance of: leadership both at the Board and at the front line people who are empowered and engaged a culture built on collaboration and continuous improvement, where it’s safe to learn co-production – engagement, empowerment and ‘lived experience’. Workshops, seminars and conversations across social media will follow in 2020 to build the thinking. So, be ready to contribute and help make sure patient safety is coming through as the top priority. And as you do, keep a copy of Roy Lilley’s latest blog in your hand. For those who don’t follow him, Roy is a health policy analyst, writer, broadcaster and commentator on the NHS and social issues. He recently posted this summary, outlining NHS electoral promises. Please do as he suggests – pin this up and bring it out every time you see a politician and whenever you have the opportunity. This way we can all ensure that these promises will be delivered.
  7. Content Article
    A few years back, I was a guest speaker at a healthcare quality improvement conference where I was approached by a doctor who said he had come to learn “what all this patient safety stuff is about". He had approached me after my presentation and, with more than a little arrogance in the tone of his voice, stated, “if only the nurses would do their jobs and follow my orders correctly, all of these errors would simply go away!” Hmmm…, a damaged and lost soul! My first reaction was to wonder what kind of slimy rock this chap had crawled out from under. However, rather than get annoyed, an emotion that rarely results in improved communication, I simply mentioned that the most current analysis of injuries resulting from patient safety incidents has revealed that the majority of serious injuries, malpractice claims and settlements result from errors or delays in diagnosis and that, the last time I checked, clinical diagnosis is primarily the purview of doctors not nurses. I figured he might want to continue the conversation, but he simply turned and walked away. The truth hurts and I was left wondering how many patients he had harmed, knowingly or unknowingly, during his career. Blaming others can be an easy out from self-examination. As I thought about this interaction later that evening, putting his insulting arrogance aside, it occurred to me that his complacency about his role as a contributor to the patient safety conundrum, and the challenges of assuring diagnostic accuracy specifically, is probably much more common than many would like to admit. Fortunately, his degree of professional arrogance is generally not the rule among compassionate professionals. Still, there is something to learn from his arrogance and from what he said. Complacency, subtle, unrecognised and perhaps pernicious, can become a malignant force. We are all prone to this. We all know that caring for patients, especially for vulnerable patients, is fraught with hazards. We work in highly complex environments, interacting with innumerable patients and professionals every day, each of whom brings strengths and liabilities into the equation we call healthcare. We all acknowledge that there are deficiencies in the structures and processes of healthcare systems and these numerous deficiencies can contribute to patient harm. Anyone who has spent time working in healthcare settings can point to examples of poor leadership, unsafe and unjust cultures, demand-based management and flawed or inadequate healthcare processes that may adversely affect the provision of care and can degrade professional morale. We have all been there. Well-documented deficiencies in the structures and processes of healthcare certainly encumber those working to actually provide care. Frontline staff working under pressure can and will make mistakes; even in institutions where robust efforts have been made to support staff and specifically improve the working environment on the frontlines, mistakes will still occur. Human beings make mistakes, and even though our processes can be standardised to reduce variability and enhance ease of performance, mistakes still will occur, especially in the domain of diagnostic accuracy where standardisation is not so robust and cognitive insufficiencies and biases abound. Caring for patients is complicated stuff! Healthcare professionals do not get up in the morning intending to harm anyone, but normal human liabilities can impair our performance. Often we do not even recognise our own liabilities or are unaware of the environmental factors that can enhance them. Workplace complexities and associated stressors such as fatigue, hunger, patient volume and acuity complexity can all contribute to distractions in an already task-saturated environment. If we also factor in outside family, social and economic pressures of various kinds, which we rarely leave at home entirely, the stage is often set for mistakes to occur, sometimes very serious mistakes. The aviation industry is an example of a highly reliable industry where safety is paramount and is often held up as a standard of performance to strive for in healthcare. But an A&E unit is a much more complex and relatively uncontrolled environment than the flight deck of an Airbus 320. In my view, the aviation metaphor commonly falls short when compared to healthcare. As a physician who has also worked in the aviation community for part of my career, I feel that although important lessons can be learned and shared from the aviation industry, the aviation environment is not a mirror image of the healthcare environment. Anyone out there ever made a mistake when caring for a patient? I have made many, I suspect, most unknown to me and of little or no consequence to my patients. I did make a more serious mistake once and my patient, a 9-month-old child, was dangerously but not permanently harmed. When oncologists make mistakes, the consequences can be catastrophic as chemotherapy agents are dangerous. The truth is, I was complacent and didn’t see the potential for harm coming right at me; my fault – or at least that was how I viewed things. I became a ‘second’ victim as a result of this incident and it still resonates with me, all these years later. Hospitals with strong committed leadership are attempting to address the challenges that those on the frontlines must face every day, especially in settings such as A&E units, but one cannot simply design out all of the confounders. There are some excellent examples of robust, patient and staff-focused leadership, safe and just cultures and collaborative management, and these should be emulated nationwide. This all brings me back to the arrogant doctor who wanted to blame the nurses for “all this patient safety stuff”, and his inherent failure to recognise his own singular, important role in the patient safety conundrum. I suspect that this is a natural tendency, as healthcare professionals do not ordinarily see themselves as sources of harm, a concept that is counterintuitive to who we think we are and the excellence in care we strive to provide. The fact is that we may all suffer from some degree of professional complacency. We may often fail to recognise environmental and situational risks, and, more importantly, to admit to our own personal liabilities, and, thus, the risks we bring into the healthcare environment. Though we all recognise how complex the provision of healthcare can be, we may not fully appreciate that we are also part of that complexity. Our inability to recognise the often subtle but inherent risks we bring to our patients in all healthcare settings is surely an independent variable in the calculus of providing patient safe care. So, I propose the following for all healthcare professionals – each day, before we enter our hospital or surgery, care home or whatever, please pause and repeat the following mantra: “I am a kind and caring professional about to enter a complex healthcare environment where patients may be harmed every day. I admit to myself that although I always intend to serve my patients as best I can, I also inherently represent a source of risk for them and I may make mistakes that can result in harm. Though I may wish to deflect responsibility onto insufficiencies in structures, processes, leadership, culture, managers and even other colleagues, the fact is that I am also a unique risk to my patients. I will be very careful, every day, in every way, with every patient under my care, all the time; and I will strive to be even better tomorrow.” Read Dan's full length article: Structures, processes and outcomes for better or worse: Personal responsibility in patient safe care
  8. Community Post
    The US-based Leapfrog Group is a nonprofit organisation that routinely gauges hospital performance to inform purchaser choices as they navigate the healthcare system. While there are discussions on the value of the ratings ... they still pack a punch for organizations who do or don't do well. The latest set of numbers are out: Megan Brooks. One Third of US Acute-Care Hospitals Get 'A' on Patient Safety: Survey - Medscape - Nov 07, 2019.
  9. Content Article
    The content covers six characteristics fundamental to a healthy culture: Inspiring vision and values Goals and performance Support and compassion Learning and innovation Effective teamwork Collective leadership.
  10. Content Article
    This guide includes: analysis of the key concepts in spreading ideas evidence on what is known about what works to spread improvement practical suggestions for planning communications, engaging the right people, sustaining interest in the work and celebrating and sharing achievements.
  11. Content Article
    The Quality Accounts FAQs on how to produce and publish your Quality Account, including: who to share your Quality Account with how to publish your organisation's Quality Account how to access the indicator data through the NHS Digital indicator portal the technical definitions of indicators and the dates when specific data sets are available, including the Quality Accounts Data Dictionary Quality Accounts audit guidance Quality Accounts reporting arrangements.
  12. Content Article
    This report features practical solutions from staff. Frontline clinicians attended workshops to help highlight the issues and identify what needs to change to keep services safe when facing surges in demand.
  13. Content Article
    The book blends literature on the nature of practice with diverse and eclectic reflections from experience in a range of contexts, from healthcare to agriculture. It explores what helps and what hinders the achievement of the core goals of human factors and ergonomics (HF/E): improved system performance and human wellbeing. The book should be of interest to current HF/E practitioners, future HF/E practitioners, allied practitioners, HF/E advocates and ambassadors, researchers, policy makers and regulators, and clients of HF/E services and products.
  14. Content Article
    Drawing on a dizzying array of case studies and real-world examples, together with cutting-edge research on marginal gains, creativity and grit, Matthew Syed tells the inside story of how success really happens - and how we cannot grow unless we are prepared to learn from our mistakes.
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