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Showing results for tags 'Organisational learning'.
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Event
Learning from patient safety incidents
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 and is aligned with the new Patient Safety Syllabus 2021. Key learning objectives: Understand the new patient safety landscape Understand the need for proportionality of investigation Learn how to use a range of techniques for conducting PSIIs Understand how to write an impactful improvement plan Consider how your current approach to patient safety investigations compares to the agreed national standards Understand typical pitfalls and -
Content Article
In my previous blogs, I explored why I developed the model of ‘Safety Chats’ and how they were conducted. The essential elements of these chats are very simple: Talk to staff about safety in the real world of their team. Ask them to explore what is safe and not safe. Engage them in the idea that they are the best people to suggest or lead change in their team. None of this conversational approach is particularly complicated and yet it is so often not undertaken. The exploration of positive experience (what makes you safe/feel safe?) is so often not considered when as -
Event
Investigation and learning from deaths in the community/primary care
Patient Safety Learning posted a calendar event in Community Calendar
This conference focuses on investigating and learning from deaths in the community/primary care. The conference focuses on the extension of the Medical Examiner role to cover deaths occurring in the community and the role of the GP in working with the Medical Examiner to learn from deaths and to identify constructive learning to improve care for patients. The conference will also focus on implementation of the new Patient Safety Incident Response Framework and learning from a primary care early adopter. For further information and to book your place visit https://www.healthcareconference -
EventThis one day masterclass will focus on a toolkit to allow organisations to use patient experience and incident to improve patient safety. The Toolkit uses 3 phases: planning, implementation and review. The Francis Report showed that the NHS had stopped listening to the needs of its users. Patient experience is still an underutilised tool in the armoury of a healthcare organisation and commissioners. The toolkit uses the priorities of the Francis Report to improve patient experience and patient safety. These include putting patients first, openness, candour, accountability, complaints hand
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Investigation and learning from deaths in NHS trusts
Patient Safety Learning posted a calendar event in Community Calendar
By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts and will reflect on learning from deaths. There will be a focus on mortality review during the Covid pandemic and how mortality investigation should be managed in these cases. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever -
News Article
Hundreds of stillbirths wrongly certified as 'unexplained'
Patient Safety Learning posted a news article in News
More than 80% of UK medical certificates recording stillbirths contain errors, research reveals. More than half the inaccurate certificates contained a significant error that could cause medical staff to misinterpret what had happened. The study, published in the International Journal of Epidemiology, also shows that three out of four stillbirths certified as having an "unknown cause of death" could, in fact, be explained. A team from the Universities of Edinburgh and Manchester examined more than 1,120 medical certificates of stillbirths, which were issued at 76 UK obstetric un -
Content ArticleKey messages: Almost 80% of Medical Certificates of Stillbirth in the UK contained errors; 55.9% had a major error that would alter MCS interpretation. 43.3% of all stillbirths were officially registered as being of ‘unknown cause of death’ (COD); 78% of these had an identifiable primary COD. Fetal growth restriction (FGR) was the leading primary COD (24.6%); many such deaths may have been preventable. With basic guidance, non-expert reporters can redress one of these core errors: converting ‘unexplained’ to explained deaths (principally FGR and placental conditions).
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Safety Chats: Part 3 - Starting the conversation
Gina Winter-Bates posted an article in Good practice
Previous blogs in this series explored the personal and evidence basis for having honest conversations about safety at the frontline of healthcare. There is often a perception that we are affording staff the opportunities to be open but this can be derailed when there is an unheard consequence in having an open conversation. This could be a for a number of reasons, many of which were identified in the C-LINK Consulting article 'Don't let the 'iceberg of ignorance' sink your company': Staff may be uncomfortable sharing bad news with either their bosses or team (Mum effect). -
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Content ArticleThe study was conducted at a multi-site acute NHS Trust in London, which consists of five acute sites and a range of community services. The Trust is one of the largest in the country, with an average of over 1,000 complaints per year between 2015 and 2019. Key findings of this study included: Confusion and lack of awareness of routes for raising concerns, both among patients and frontline staff. Investigative procedures structured to scrutinise the ‘validity’ of complaints, rather than focusing on improvement. Data collection systems not being set up to effectively su
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EventThis national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework). NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version with the revised framework due in Spring 2022. Local systems and organisations outside of the early adopter areas are free to use the already published version of the
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Content ArticleThe authors found four key themes were derived from these interviews: trauma, communication, learning and litigation. They concluded that there are many advantages of actively involving patients and their families in adverse event reviews. An open, collaborative, person-centred approach which listens to, and involves, patients and their families is perceived to lead to improved outcomes. For the patient and their family, it can help with reconciliation following a traumatic event and help restore their faith in the healthcare system. For the health service, listening and involving people
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Content ArticleCoroner's concerns The NHS 111 telephone triage service uses the NHS Pathways computer system to triage patients via pre-determined question/answer based algorithms. The pre-determined questions are the same whether the caller is an adult or a child. Alex struggled to comprehend some of the medical terminology used during these calls. Call handlers are not permitted to deviate from the prescribed wording of the pre-determined questions, and this created confusion and inconsistency in the patient’s answers. Consideration should be given as to how young and/or vulnerable patients can be a
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