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Showing results for tags 'Organisational culture'.
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News ArticleThe boss of a NHS trust that asked hospital staff for fingerprints and handwriting samples as it hunted a whistleblower is stepping down. Dr Stephen Dunn will leave West Suffolk NHS Foundation Trust in the summer after seven years as chief executive. An independent inquiry into the way management handled the affair is expected to report in the autumn. In 2018, Jon Warby received a letter two months after the death of his wife, Susan. It claimed mistakes were made during her bowel surgery. An inquest into her death was subsequently told how she had been given glucose instead of s
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To err is human, to apologize is hard (JAMA, July 2021)
PatientSafetyLearning Team posted an article in Culture
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Building a culture of learning and accountability: learning from when things go wrong
Sam posted a calendar event in Community Calendar
untilWhen things go wrong in health and social care, there can be significant consequences for patients, staff, and leaders. But, too often, the voices of people who use services and their families have gone unheard, while staff have feared being blamed for mistakes that result from systemic failings or human error. So how can health and social care leaders at all levels create a just culture, where mistakes lead to learning? And how can organisations take accountability for learning and improving after something goes wrong? The King’s Fund is co-hosting this virtual conference in partner -
Content ArticleIn the two weeks before his death Robbie was seen seven times by five different GPs. The child was seen by three different GPs four times in the last three days when he was so weak and dehydrated he was bedbound and unable to stand unassisted. Only one GP read the medical records, six days before death, and was aware of the suspicion of Addison's disease, the need for the ACTH test and the instruction to immediately admit the child back to hospital if he became unwell. The GP informed the Powells that he would refer Robbie back to hospital immediately that day but did not inform them that
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EventThis one day masterclass will focus on how to use behavioural insights and 'Nudge Theory' to look at patient safety and safety culture. "Nudge Theory is based upon the idea that by shaping the environment, also known as the choice architecture, one can influence the likelihood that one option is chosen over another by individuals. A key factor of Nudge Theory is the ability for an individual to maintain freedom of choice and to feel in control of the decisions they make. " Imperial College London, What is Nudge Theory? Nudge-type interventions have the potential for changing behaviou
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The key topics covered in this video are as follows: What is human factors/ergonomics and how does it relate to healthcare? (at 2 mins and 20 secs) What is the value of high reliability to healthcare? (at 9 mins and 20 secs) How can patient insights and contributions help to create more highly reliable organisations? (at 17 mins and 40 secs) Reflections on the impact of culture and barriers pose to increasing resilience and learning from safety. (at 20 mins and 45 secs) The role of ‘speaking up’ initiatives. (at 25 mins and 40 secs) Incident reporting and th -
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Report finds ethnic minority staff face 'regular discrimination'
Patient-Safety-Learning posted a news article in News
A new report published by Devon Clinical Commissioning Group, consultancy Nous reveals worrying examples of discrimination towards ethnic minority staff. It has been noted that attempts at progress and improving equality has had 'limited effectiveness' with ethnic minorities experiencing minimal resources to carry out their roles. Findings showed ethnic minorities faced barriers to appropriate care with staff experiencing "substantial inequalities". Read full story.(paywalled) Source: HSJ, 10 June 2021 -
Content ArticleRelated content in this series Introductory blog: Improving patient safety through high reliability Video conversation: The importance of culture in achieving high reliability in healthcare
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Content ArticleThe following guideline will help to support a consistent and fair approach to the management of staff following events involving healthcare associated harm. It is based on the following premises: Healthcare is a complex and high risk activity prone to healthcare associated harm. Weak systems create the conditions for and the inevitability of human error. Latent conditions preceding adverse events include poor decisions, poor designs, poor supervision, inadequate tools and equipment, and the cumulative actions of individuals. Capturing, tracking and learning from health
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Content ArticleThis report shares the learning which has been identified as a result of research looking at how the Freedom to Speak Up role could be introduced in Primary Care and Integrated Settings. It illustrates some of the challenges in implementing Freedom to Speak Up in primary care, as well common themes and learning. The report identifies two models to support primary care organisations in developing their speaking up arrangements, bridging across the silos of GP, dental, optometry and pharmacy: Freedom to Speak Up within an organisation – an individual organisation model – such as a GP
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News ArticleOversight failures, a fearful workplace culture and lax quality standards for years at a Veterans Affairs hospital in Arkansas, USA, allowed a pathologist who was routinely drunk on the job to misdiagnose thousands of veterans — sometimes with dire or deadly consequences, a new investigation has found. Hospital leaders “failed to promote a culture of accountability” that would have led more of the doctor’s colleagues to come forward with accounts that his behavior was putting patients at risk, according to the report released Wednesday by VA’s Office of Inspector General. But the staff me
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News ArticleThe Care Quality Commission (CQC) has revealed a new strategy that will place more emphasis on a patient’s experience of care and seek to get a better grip on ”care settings where there’s a greater risk of a poor culture going undetected”. Ian Trenholm, chief executive of the CQC told HSJ the CQC’s new approach would be informed by the belief that ”people’s experience of care is driven as much from the way different providers will interact with each other – both public sector, private sector, third sector - in a place as much as it by the individual performance of individual providers.”
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News ArticleAlmost a fifth of nurses who left the profession cited a negative workplace culture as a reason for leaving along with almost a quarter saying they were under too much pressure. The nursing regulator, the Nursing and Midwifery Council (NMC) warned there could be an exodus of registered nurses after the coronavirus pandemic in its latest annual report. Despite a record number of nurses and midwives joining the profession across the UK, the NMC said pressure on frontline nurses could drive many away. In a survey of 5,639 nurses who left the register between July 2019 and June 2020
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Play video The key topics covered in this video are as follows: Why is high-reliability important in addressing avoidable harm? (at 4 mins 25 secs). How culture impacts on the implementation and use of incident reporting solutions (at 8 mins). How incident reporting rates have changed during the pandemic (at 14 mins 25 secs). Positive reporting and learning from success (at 16 mins 25 secs). The role of Board members and non-executive directors understanding of incident reporting and risk management (at 22 mins 50 secs). Considering the importance of B -
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We need to stop calling NHS staff heroes – for a very important reason
Patient Safety Learning posted a news article in News
When we put people on a pedestal, my experience is that they are less likely to be asked, ‘are you OK?’, writes Samantha Batt-Rawden, a senior registrar in intensive care medicine. Like many she has been touched by the groundswell of support from the public. But there’s a problem with this hero image, she says. "It’s not just that many NHS staff are feeling increasingly uncomfortable with being hailed as heroes for what they see as simply doing their jobs. Of course, we were going to step up to the plate when the COVID-19 pandemic hit. As doctors it was our duty. There was never any -
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