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Found 219 results
  1. Event
    until
    When 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
  2. Content Article
    In 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
  3. Content Article
    Background In 2018, SIM was selected for national scaling and spread across the Academic Health Science Networks (AHSNs). The High Intensity Network (HIN) has been working with the three south London Secondary Mental Health Trusts: The South London and Maudsley NHS Foundation Trust, Oxleas NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust, and the Metropolitan Police, London Ambulance Service, A&E, CCG commissioners, and the innovator and Network Director of the High Intensity Network. The model can be summarised as: A more integrated, infor
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    The report sets out several recommendations including: 1.Improve the engagement of parents in reviews by standardising and resourcing local processes to ensure all bereaved parents are told a review will take place and have ample opportunities at different stages to discuss their views, ask questions and express any concerns as well as positive feedback they have about the care they received. Action: Trusts and Health Boards, staff caring for bereaved parents 2.Provide adequate resourcing of multidisciplinary PMRT review teams, including administrative support. Action: Trus
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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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    Related 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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    This research presents a number of factors contributing to poor reporting in healthcare as well as suggestions for system improvement drawn from the car industry. Amongst these, an increase in specificity of reporting method, need for long term data and recognition of behavioural differences between different sources could lead to better reporting methods and potentially reduce existing levels of underreporting. It also considers that bringing device performance reporting outside the context of incidents only would lead to improved knowledge and learning for all stakeholders. Thus, a diff
  10. Community Post
    The Academy of Medical Royal Colleges have published the first National patient safety syllabus that will underpin the development of curricula for all NHS staff as part of the NHS Patient Safety Strategy: https://www.pslhub.org/learn/professionalising-patient-safety/training/staff-clinical/national-patient-safety-syllabus-open-for-comment-r1399/ Via the above link you can access a ‘key points’ document which provides some of the context for the syllabus and answers to some frequently asked questions. AOMRC are inviting key stakeholders to review this iteration of the syllabus (1.0)
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    After watching the video, participants should be better prepared to: Acquire an understanding of the concept of a "medical error". Appreciate the safety movement. Understand the culture of safety. Illustrate real examples of adverse events and their sequelae. Identify a high reliability organisation.
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    Let’s start with a story I was once told… There once was a very successful farmer who hired many people to work on his farm; at a glance, you could see countless heads of men and women tilling the ground. He grew very rich. The wealthier he became the more people he hired. His farmland kept increasing every year until it got to the boundary of a river. Although there were many workers, the farmer knew everyone by name and was able to account for them on a daily basis. However, over time, he noticed some workers who came to work could not be accounted for – they went missing. The farme
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    The Coroner notes that, although he was assessed at home by the midwifery team at aged 5 days, no basic observation assessments were taken, such as temperature, heart rate and respiration rate, from the deceased or his mother to confirm their wellbeing. There is no national guidance for such checks, however, University Hospital Dorset NHS Foundation Trust (UHD) have since changed their local policies to embed better safety nets. The local policy now provides guidance that at each visit up to day 10 post birth, a full set of baby and maternal observations are to be taken. The Coroner also
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  25. News Article
    Thousands of similar errors contributing to patient deaths are being repeated by hospitals despite warnings from coroners, according to new research. An analysis of four years of official reports by coroners, issued after the conclusion of inquests into patient deaths, has revealed the impact of the NHS struggling with a lack of resources and staff. Coroners found similar mistakes across hundreds of inquests. Professor Alison Leary, chair of healthcare a workforce modelling at London South Bank University, and who led the study, told The Independent: “We are missing opportunities to
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