The report makes several recommendations including:
Provide adequate resourcing for multidisciplinary PMRT review teams, including administrative support. Ensure the involvement of independent external members in the team.
Action: Trusts and Health Boards, regional/network support systems and organisations, Service Commissioners
Use the PMRT parent engagement materials to support engaging parents and families in the review process, including making them aware a review is taking place and giving them flexible opportunities at different stages to discuss their views, ask questio
What can you learn from the Nimrod disaster? At a superficial level, the specifics of this event were unique, but by delving deeper into the ‘why?’, the Review team revealed that history does in fact repeat itself.
Nimrod XV230: Parallels with healthcare. By discussing the relevance of the Nimrod XV230 event to healthcare, Martin aims to illustrate that the organisational lessons from this event are applicable to almost any industry. There are parallels with several major healthcare events.
Success, complacency and failure. The track record of the Nimrod aircraft led to a high level
The report highlights the next steps that maternity services and the CQC need to take:
For maternity services and local maternity systems
Leadership: In line with essential action 2 of the first Ockenden review, Boards must take effective ownership of the safety of maternity services. This includes ensuring that they have high quality, multidisciplinary leadership and positive learning cultures. They must seek assurance that staff feel free to raise concerns, that their concerns and adverse events lead to learning and improvement and that individual maternity staff competencies ar
The strong associations between organizational readiness to change and safety climate in nursing homes have the following implications for practice and research:
Safety climate interventions should first assess and address staff and system readiness to change.
Readiness to change assessments and safety climate interventions may also need repeating as staff turnover brings in new staff and may change these dynamics.
Whether staff skills and knowledge moderate the association of readiness to change and safety climate should also be examined in future research.
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
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
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
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.
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
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