Jump to content

Search the hub

Showing results for tags 'Personal reflection'.


More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


Forums

  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous

Categories

  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
    • Questions around Government governance
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Patient Safety Alerts
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient Safety Partners
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • Patient Safety Standards
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training & education
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous

News

  • News

Find results in...

Find results that contain...


Date Created

  • Start
    End

Last updated

  • Start
    End

Filter by number of...

Joined

  • Start

    End


Group


First name


Last name


Country


About me


Organisation


Role

Found 69 results
  1. Content Article
    A set of eLearning modules designed to educate and update clinicians on the importance of involving families wherever possible during mental health crises to improve patient care, avoid harm and reduce deaths. They were developed as a partnership between Oxford Health NHS Foundation Trust and Making Families Count, with funding from NHS England South East Region (HEE legacy funds).   The resources have been co-produced by people with lived experience as patients, family carers and clinicians, supported by an Advisory Group drawn from a wide range of expertise, tested in eleven NHS Trusts and independently evaluated.   The resources can be downloaded by NHS Trust Learning and Development teams to support a Trust-wide approach to essential learning and training.   Through short film and audio scenarios and case studies, Life Beyond the Cubicle shows why it is so important to involve family and friends, helps clinicians reflect on why they don’t do so routinely, and how they can overcome these barriers. The resources are engaging and interactive. The modules are: Introduction (includes guidance on how to use this resource) Module 1: Why do families and friends matter? Module 2: Assumptions and expertise Module 3: Feelings and fears Module 4: Confidentiality and Information Sharing Module 5: Safety planning Resources for family and friends They are free to the health and social care workforce. Further reading on the hub: Safer outcomes for people with psychosis Patient Safety Spotlight interview with Rosi Reed, Development and Training Coordinator at Making Families Count The future has been around for too long—when will the NHS learn from their mistakes?
  2. Content Article
    Calibration, defined as alignment between a person’s diagnostic accuracy and their confidence in that accuracy, is an essential component of diagnostic excellence. Miscalibration—the misalignment between a person’s diagnostic accuracy and their confidence in that accuracy—can manifest as either overconfidence or underconfidence and can have serious consequences for patient diagnosis. This resource about calibration from the US Agency for Healthcare Research and Quality (AHRQ) is primarily aimed at individual clinicians whose scope of practice includes diagnosis. It focuses on processes involved in making a diagnosis and the outcome of giving an explanatory label to patients after these processes unfold.
  3. Content Article
    The UK Covid-19 Inquiry is the independent public inquiry set up to examine the UK’s response to and impact of the Covid-19 pandemic, and learn lessons for the future. In order to fully understand the impact of the pandemic on the UK population, the Inquiry is inviting the public to share their experiences of the pandemic by launching Every Story Matters. It will inform the Inquiry’s work by gathering pandemic experiences which can be brought together and represent the whole of the UK, including those seldom heard. The output of Every Story Matters will be a unique, comprehensive account of the UK population’s experiences of the pandemic, to be submitted to the Inquiry’s legal process as evidence. Share your story here. Every Story Matters provide a toolkit that contains information and creative assets that can be used to encourage participation in Every Story Matters. Every Story Matters aims to provide inclusive methods for people to talk about their experience of the pandemic, so anyone that wants to share their story feels heard, valued, and can contribute to the Inquiry. tips on engaging people to take part in Every Story Matters print campaign assets to download online campaign assets to download information on how to use campaign assets information on accessible engagement options.
  4. Content Article
    This article from Sarcoma UK was written by Dermot’s family to develop their reflections and recommendations on the recent publication of the Healthcare Safety Investigation (HSIB) report, Variations in the delivery of palliative care services to adults. The HSIB report, Variations in the delivery of palliative care services to adults, has highlighted numerous concerns about the delivery of palliative and end of life care across England. Their investigation reveals that palliative and end of life care is ‘variable and inequitable’ across the NHS, and the report includes a series of safety recommendations and actions. To understand the impact of inconsistent palliative care, HSIB looked at the case of Dermot – a 77-year-old patient who was diagnosed with myxofibrosarcoma in March 2020, and received support from Sarcoma UK. Here, Dermot’s brother-in-law, Richard, 60, also shares the family’s insights into Dermot’s experiences and the changes that are needed to improve care for sarcoma patients. Richard and Sarcoma UK have put together their own recommendations, which provide clear, simple and positive suggestions to improve the sarcoma patient pathway.
  5. Content Article
    Dr Liz O’Riordan is a breast cancer surgeon who has battled against social, physical and mental challenges to practise at the top of her field. Under the Knife charts Liz’s incredible highs: performing like a couture dressmaker as she moulded and reshaped women’s breasts, while saving their lives; to the heart-breaking lows of telling ten women a day that they had cancer. But this memoir is more than just an eye-opening look at the realities of training to be a female surgeon in a man’s world. In addition to this high-powered, high-pressured role, Liz faced her own breast cancer diagnosis, severe depression and suicidal thoughts, in tandem with commonplace sexual harassment and bullying. And by revealing how she coped when her life crashed around her, she demonstrates there is always hope.
  6. Content Article
    Since retiring from his role in public health, Dr Bill Kirkup has focused on independent investigations into public service failures, including maternity services at Morecambe Bay and East Kent. In this podcast, Bill talks to Parliamentary and Health Service Ombudsman Rob Behrens about his career, what he's learnt during his investigations and how we can make more progress in improving patient safety.
  7. Content Article
    NHS Horizons uses SenseMaker to gather and analyse stories of real-time, day-to-day experiences to facilitate improvement in complex environments. SenseMaker is the complexity research tool that enables not only the mass data collection of rich and deep descriptions of people’s experiences, but also uses a framework incorporating “triads” and “dyads” to allow participants to categorise what their stories mean to them. The process starts with a SenseMaker survey (or a series of surveys) and ends with a Sensemaking workshop.
  8. Content Article
    This series of blog posts is written by a patient who experienced life-changing complications after surgery went wrong. In her posts, they explore the psychological needs of patients following healthcare harm, which are often overlooked during physical rehabilitation. "I believe that the emotional support given to the patient during those first few weeks can make a significant difference to their long term quality of life. That’s why I decided to write this blog, to give constructive feedback to help medical professionals learn from my experiences." Blog posts: It's about acceptance Put yourself in these scenarios Sorry - one important word Reassuring the patient My turn to apologise Emotional support Making ICU a bit more bearable Not what I wanted to hear Helping the patient forgive Not my fault either How time heals Psychological benefits of prehabilitation Talking to an independent person Be kind to angry patients Emotional intelligence Difficult conversations Forget-me-not Surgeons' coping mechanisms Showing his vulnerability A safe place to talk Social media My coping mechanisms Trusting my surgeon again Reconciliation
  9. Content Article
    NHS and social care continues to have significant challenges. This blog cannot change that but it offers food for thought on how to stay afloat.  It’s been a while since I have posted a blog. I continue to coach NHS colleagues – their calmness, focus, resilience, professionalism and ‘can do’ shining through in spades. Inspirational, appreciative leaders of teams, small and large. Our current systems and challenges are too complex to have one person at the helm taking all the decisions. We need leadership at all levels. Great leaders inspire people to have confidence in themselves. Whether you are part of a team, a team leader or leader of many, here’s four things to contemplate: 1. Reality check The Covid aftermath, understandable unrest and general distress and frustration have impacted, of course they have, but we have a dedicated, professional, caring workforce. 2. The power of appreciation Take a moment to identify and reflect on your contributions and those of your colleagues. Appreciate those contributions. Make time to share them with each other. Individually and collectively feel proud. 3. Strengthen your resilience I can’t remember where I read this, but a simple way to focus the mind and build your resilience is to start each day with this simple reminder: I am … add in the words that best describe your talent and experience. I have … add in things that support and energise you at work and home. I will ………..your intentions for that day, this week. 4. Look out for each other Tune in. Sometimes we just want someone who will listen, a space to talk to a colleague, friend, coach, mentor. If you don’t already have this, think about who could help. In my experience, how we care for each other and appreciate our respective contributions helps to sustain us on the brightest days and the not so bright. Thanks for reading this. I have used this quote before but it seems apposite just now: "She stood in the storm and when the wind did not blow her away, she adjusted her sails." Elizabeth Edwards. Further blogs from Sally: Keep your light shining bright – three tips Swimming with the tide Standing tall in the storm
  10. Content Article
    To thrive and deliver the best healthcare, healthcare professionals depend on their ability to self-reflect and adapt their working behaviours. This skill is developed through self-awareness, an openness to alternative perspectives, proactively seeking feedback and a willingness to change behaviours as a result of reflecting. Transformative reflection is a type of reflective practice that can transform a person's sense of work-based identity, sense of purpose and how they work, ultimately influencing the collective wellbeing. This guide explains what transformative reflection is, how to create an environment in which it can take place and suggests formats and resources to aid organisations in encouraging transformative reflection.
  11. Content Article
    Commentary from quality and safety leaders on the persistence of adverse events in care delivery — and where health care organisations should go from here. Further reading: The safety of inpatient health care Constancy of purpose for improving patient safety.
  12. Content Article
    Dawn Stott has worked in healthcare for many years. Her passion is customer care and service improvement. She has designed courses to support healthcare providers improve practice through capturing enthusiasm and sharing best practice.  For the last thirteen plus years she has worked as CEO of the Association for Perioperative Practice (AfPP), a healthcare charity that supports theatre personnel who work in hospitals. When faced with lock down, Dawn shared her thoughts and feelings, via regular emails with her work team. The result is a culmination of her musing, along with some impressions, observations and learning that formed the basis for her book.  When the world was side swiped by Covid-19, Dawn was able to deploy her HQ team effectively to work from home but also kept the office open and functioning to ensure the charity’s members, who were working on the frontline, were supported. This hybrid way of working has now become the new normal for many organisations. At the outset of the pandemic and working disparately, she decided the best way to bring everyone together was through one communication. A morning ‘check in’ if you like. The purpose was to raise morale, lift spirits and also to pass on important messages to ensure the business continued to function effectively. Her intention was for the musings to be uplifting, inspiring and to give her colleagues the opportunity to know that it was OK to not be OK. As a result of responses from her colleagues and family, suggesting she get them published, she decided to follow the positive route rather than listening to those inner voices that challenge us daily when they say such things as: ‘Who would want to read them?’ ‘Nobody knows you outside of your work circle, so why would they be of interest?’ ‘Who do you think you are?’ Dawn assures you that her musings will remind you of what we were going through as a nation, but also, she hopes, inspire you to look at things differently, be kind and embrace the moment – even during difficult situations.
  13. Content Article
    "One family told me their mum had only been waiting six hours on the floor for an ambulance. Only six hours. For a moment I thought this was a positive outcome. A patient in their 80s, lying on a cold hard floor for the equivalent of three quarters of my shift and I felt this was good patient care. Sadly, this genuinely was better than earlier in the year with patients waiting over 12 hours on the floor and an additional 16 plus hours in an ambulance. I cried when I got home about how far we’ve fallen." An anonymous junior doctor shares his experience on the NHS frontline.
  14. Content Article
    Transformative reflection is based on the idea is that people's perspectives on the world around them change when they reflect on new experiences that challenge their world view. NHS England (NHSE) says that reflection can be hugely valuable for patient care, staff morale and for doctors themselves. In this interview, Dr Alison Sheppard, a national clinical fellow who contributed a new NHSE guide on transformative reflection, talks about what transformative reflection is and how it can be helpful for doctors.
  15. Content Article
    In this BMJ article, consultant in geriatrics and acute medicine David Oliver describes his experience of being an inpatient in the hospital he works in. He talks about how his three-day admission with respiratory syncytial virus and pneumococcus has given him a better understanding of what patients experience in hospital. He describes how lack of privacy, poor quality food and noise affected him during his stay as an inpatient. He also highlights that although all staff were professional and kind, they were clearly overworked and unable to focus on more 'minor' concerns that patients have.
  16. Event
    Perioperative practitioners have worked tirelessly to rise to the challenges presented in recent years, and now continue to face the challenge of managing record-breaking waiting lists. Theatre work is challenging. You’re on your feet all day, mentally engaged and, at times, emotionally charged. This study day gives you an opportunity to focus on your own health and wellbeing as well as the welfare of your patients. "If we look after ourselves, we can look after others!" Topics will include: Review of mental health wellbeing and how to optimise it Health diet and fluid intake The benefits of exercise Optional Tai Chi taster session The importance of sleep and rest Debriefing and feedback to prevent burnout and PTSD Menopause awareness Open debate: Achieving a work-life balance in a demanding perioperative role Book
  17. Event
    until
    The uncertainty and anxiety that come with the experience of complexity can be overwhelming. It can be hard to think clearly and act wisely, and our wellbeing can easily suffer. The COVID-19 pandemic has made these experiences an everyday occurrence for many people, and the need for us to work clearly, wisely and healthily has never been more pressing. These Organisational Development workshops from the King's Fund will lift the lid on complexity. Together, you’ll explore how encouraging ourselves and others to understand and acknowledge the loss of control when faced with complexity can help us, our teams and our wider organisational systems survive and even thrive in conditions of uncertainty. The workshops will help you: make sense of the messy reality of complexity, accurately categorise different aspects of that reality and be able to choose appropriate, measured, responses understand your own preferences and strengths in relation to the complexity around you and develop strategies to stretch beyond them help yourself and others be their best during uncertain times. Join one or two sessions, or the whole series. Buy tickets
  18. Event
    The uncertainty and anxiety that come with the experience of complexity can be overwhelming. It can be hard to think clearly and act wisely, and our wellbeing can easily suffer. The COVID-19 pandemic has made these experiences an everyday occurrence for many people, and the need for us to work clearly, wisely and healthily has never been more pressing. These Organisational Development workshops from the King's Fund will lift the lid on complexity. Together, you’ll explore how encouraging ourselves and others to understand and acknowledge the loss of control when faced with complexity can help us, our teams and our wider organisational systems survive and even thrive in conditions of uncertainty. The workshops will help you: make sense of the messy reality of complexity, accurately categorise different aspects of that reality and be able to choose appropriate, measured, responses understand your own preferences and strengths in relation to the complexity around you and develop strategies to stretch beyond them help yourself and others be their best during uncertain times. Join one or two sessions, or the whole series. Buy tickets
  19. Event
    until
    The uncertainty and anxiety that come with the experience of complexity can be overwhelming. It can be hard to think clearly and act wisely, and our wellbeing can easily suffer. The COVID-19 pandemic has made these experiences an everyday occurrence for many people, and the need for us to work clearly, wisely and healthily has never been more pressing. These Organisational Development workshops from the King's Fund will lift the lid on complexity. Together, you’ll explore how encouraging ourselves and others to understand and acknowledge the loss of control when faced with complexity can help us, our teams and our wider organisational systems survive and even thrive in conditions of uncertainty. The workshops will help you: make sense of the messy reality of complexity, accurately categorise different aspects of that reality and be able to choose appropriate, measured, responses understand your own preferences and strengths in relation to the complexity around you and develop strategies to stretch beyond them help yourself and others be their best during uncertain times. Join one or two sessions, or the whole series. Buy tickets
  20. Content Article
    The Point of Care Foundation have developed Team Time in response to the Coronavirus pandemic. Team Time is a 45-minute reflective practice that is run and facilitated online and provides an opportunity for people taking part to share experiences of their work in health and social care. As with Schwartz Rounds the focus is on participants’ emotional and social response to their work. However, unlike Schwartz Rounds, the audience is limited in size and is intended to be drawn from an area/department of a health/social care site rather than from across the organisation. The audience will comprise colleagues who have ‘common cause with others in a specialty/pathway’ and consider each other colleagues in the work of that area.  Please note that Team Time training is available only to trained Schwartz Rounds facilitators.
  21. Content Article
    We have probably all suffered from imposter syndrome at some point during our career. Doubted our self and our abilities. However, if we aren't confident in ourselves and how we do our jobs it could impact on the patients we look after. Here are my tips on how to get to grips with your imposter syndrome. Imposter syndrome – that feeling of being not enough and the more you notice it the bigger it becomes. It lands in the pit of your stomach, it’s that voice that says "you, really?". And rather than going away, it shouts a little louder and risks being a real interference to you being at your absolute best. It's common in high achievers, perfectionists. A friend recently asked me if we are born with it. I don’t think so but I do think it has its roots in early labelling – he’s the bright one, she’s the kind one. And we learn to hide it. I did a quick straw poll last week. Everyone I spoke to shared their experiences of imposter syndrome with a range of triggers: moving from being ‘in training’ to someone who is expected to know all the answers, being invited to give a big presentation, leading a new team, starting a new job, chairing an expert committee (expert – now there’s a scary word). In my experience it crops up all the time in coaching sessions. Often at work, people are concerned they may appear weak or not quite up to the job. It may be easier to simply keep quiet. Coaching is a safer space, you won’t be judged, you will be encouraged to find a solution for your imposter syndrome. You can choose to ignore it, but please don’t. At worst case it could mean that your most important lifesaving contribution, that key piece of information that changes the approach the team is taking for the better may not surface. "Its ok, they know better than me" is not the answer. So here’s my three tips drawn from my experience of working this through with others. 1. Get to know your imposter syndrome better It’s really hard to work on something you don’t really understand. Some of us like to talk things through with a trusted friend or colleague, others favour quiet reflection. Whatever your preference, take time to get to know your version of imposter syndrome a little better: when it lands how often what triggers it how it makes you feel. Start to build that picture. This information is essential. It is worth investing the time. 2. Name it This may strike you as weird, but the simple act of naming something helps us to have a shorthand to use when it joins us (and it will be back) and gives a pass through to dealing with it. I have worked with people who use a christian name, a cartoon character, the weather. For me it is a jackdaw (heavy landing – solid - stays a little while). Use whatever works for you. 3. Work on it Armed with this new level of understanding: Remind yourself why you were appointed/asked/whatever your situation. Talking it through may be enough. Sometimes it is worth writing down the skills: knowledge and ingenuity that you bring to the table so you can bring it to mind at a moment’s notice. Re-connect to the great feedback you have received, solicited and unsolicited. Appraisals, 360s, that lovely email or phone call thanking you, the one that turned a rotten day into one with a better ending. Once these are centre stage, they will help to quieten that doubting thomas of a voice. And if you know there are particular triggers for you – that meeting, that person – work out your own private handling strategy. A little re-framing works wonders, especially when served with a bit of humour. Then the next time your imposter syndrome pays you a visit: remember the expertise you bring to the table, that great feedback prepare as you always would and show your best self stay calm, stand tall, make your voice count. Oh and if you really are out of your depth, an honest answer, "that’s a new one on me", and a commitment to come back with an answer as soon as possible will always help you out. No one can be expected to know everything, not even an expert!
  22. Content Article
    The Patient Safety Database (PSD), previously called Anesthesia Safety Network, is committed in the delivery of better perioperative care. Its primary goal is to make visible the lack of reliability of healthcare and the absolute necessity to build a new system for improving patient safety. They have begun by developing an open and anonymous incident reporting system focused on non-technical skills. Each quarter they summarise in their newsletter cases reported on the platform. Read the latest newsletter.
  23. Content Article
    Ehi Iden, hub topic lead for Occupational Health and Safety: OSHAfrica, reflects on a patient safety incident early on in his career. In the early days of my career, I worked with clinical teams while managing a hospital and later a network of hospitals. I must say, the experience I gathered in these different roles shaped me into what I am today. I can fit into healthcare conversations easily because of these early relationships and interactions with clinical experts. When I look back to my experience as a hospital administrator, a particular incident keeps coming back to mind; I sometimes link this to my later involvement in patient safety but most times I feel it is my conscience speaking to me. There was a patient we were trying to give a surgical intervention to; although he was already in a bad condition, he stood a chance to survive yet he died. We had an antenatal case we had managed from conception and the lady had opted for an elective caesarean section (CS). When she was term, we brought her in and prepared her for the theatre. At the time set of the surgery, our anaesthetist was not available; he was assisting another surgery in another facility, but he gave us a name of his anaesthetist colleague we could use for this patient. We brought this new anaesthetist in to assist in the patient’s CS. While we stretchered in the lady for her elective CS, a severe emergency case was rushed in needing an urgent surgical intervention. This case obviously had to override the elective CS in order of triage. We returned the lady to her ward while we rushed to the emergency case. The medical team that was going to operate on the CS patient was now needed for this new case. About 20 minutes into the surgery, our lead surgeon came out of the theatre with an upset look on his face. I sensed something was wrong and I immediately led him into my office which was near to the theatre and locked the door. I asked him what happened? He told me that there had been an anaesthesia accident. The new anaesthetist we brought in to assist with the surgery had not understood our anaesthetic machine as he had never used it before. He had used the machine incorrectly and had given the patient an overdose of gas and the patient’s heart packed up. The lead surgeon was very upset. I was thinking, this could have been my Dad, my Mum or any of my family members; it was a totally life-changing experience for me. The relatives of the patient were notified that the patient had died; there was wailing and shouting in the hospital. I locked myself inside my office and cried because I knew this patient should not have died from an error of one man. I imagined the pain we had caused the family; the grief and the vacuum we created by our error. It was all too much horror for my fragile heart to deal with at that time. But the greatest mistake we made was that the error was never discussed among the team for us all to learn from and we were also not honest enough to own up to the patient’s relatives. This incident led me into researching and reading materials on medical safety and this was how I got into patient safety advocacy. But when I look back at the incident today, was it the anaesthetist’s fault? No not at all; it was the fault of the system. The anaesthetist should not have been allowed access to that machine in the first place as he had not been trained to use that machine. This was where we should have trapped the risk before it got to the patient. In safety, when you change or replace a machine or a piece of equipment your policy must be reviewed to capture the new equipment and users must be trained on the new machine in its specifications and peculiarities. This is what happens in aviation. A pilot cannot fly an aircraft which he has not been simulated to fly and this is one of the reasons why aviation is still one of the safest sectors in the world today.[1] Having established that it was a system error, we should have also been professional and honest enough to let the relatives of the patient know what had actually happened. When we are honest it shows clear transparency, but when we try to sweep things under the carpet it is mostly misunderstood that our actions could have been deliberate. As I am writing this article, I am sure the relatives of the patient, many years down the line, still don’t know what actually happened. Following the Communication and Optimal Resolution (CANDOR) processes,[2] we should have made an early and honest disclosure of the adverse event known to the patient’s relatives, offered them an apology, refunded their payment and let them know how much this mattered to us and what we were going to do to improve our system. Our actions totally contravened all required amicable and fair resolution for the patient’s family. Owing to the fact that every man is fallible – this is why we are mere mortals in the first place – there may be errors but losing the opportunity to learn from those errors is deliberately creating new levels of errors. We never discussed what happened to our patient. I was the only one who got to know about this incident outside the clinical team who were in the theatre when this happened. The Medical Director may not have even known, so the case was never discussed and we could never all learn from it. When I think of this, I feel we need more openness and information sharing in healthcare, allow teams to discuss and share experiences, give room for reporting without blame, design a system that encourages patient safety conversation and liberalise communication processes. Each time this incident crosses my mind, I think of the lady who we had originally booked for elective CS. This clinical team was put together for her CS before the sudden emergency that came to take her place. She never knew what happened. The evening of that same day her CS was done and she had her baby boy who should be a grown man now. This brings to mind the bible verse Isaiah 43.4 “…I will give people in exchange for you, nations in exchange for your life”. Could this have been what happened? No, the system is what killed the patient and I think we should all own up to this. References Kai-Jorg S. Pilot training: What can surgeons learn from it? Arab Journal of Urology 2014;1: 32-35. Agency for Healthcare Research and Quality (AHRQ). Communication and Optimal Resolution (CANDOR).
  24. News Article
    As the world writhes in the grip of Covid-19, the epidemic has revealed something majestic and inspiring: millions of health care workers running to where they are needed, on duty, sometimes risking their own lives. In his article in the New York Times, Don Berwick says he has never before seen such an extensive, voluntary outpouring of medical help at such a global scale. Millions of health care workers are running to where they are needed, sometimes risking their lives. Intensive care doctors in Seattle connect with intensive care doctors in Wuhan to gather specific intelligence on what the Chinese have learned: details of diagnostic strategies, the physiology of the disease, approaches to managing lung failure, and more. City by city, hospitals mobilise creatively to get ready for the possible deluge: bring in retired staff members, train nurses and doctors in real time, share data on supplies around the region, set up special isolation units and scale up capacity by a factor of 100 or 1000. "We are witnessing professionalism in its highest form, skilled people putting the interests of those they serve above their own interests." Read full article Source: New York Times, 23 March 2020
  25. Content Article
    As Psychology / Human Factors advisor to the UK surgical patient safety learning group (CORESS), and having published on clinical excellence and patient experience issues, Narinder Kapur recently had the unique experience of being a surgical patient. The author discusses the gained insights and learned lessons that could help improve the patient hospital experience and also patient safety.
×
×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.