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Found 35 results
  1. Content Article
    ‘Work as done’ Because healthcare is constantly evolving and complex, by looking more closely at everyday work and finding out what actually happens, it allows an understanding of what it is, that frontline clinicians do to ensure successful outcomes. This is termed as looking at 'work as done' and informs us about the nuances, the adjustments, the compromises, the workarounds, the actions and the decision making that is taken to meet the needs of the patients they are caring for. ‘Work as done’ is a combination of expertise, clinical decisions, experience and tacit knowledge. It is
  2. Content Article
    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
  3. 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)
  4. Content Article
    A year ago, you implemented a new approach to auditing at Barnsley. Can you tell us what prompted it? In healthcare, we tend to measure safety by looking at negatives. The number of falls, the number of category 2 pressure ulcers, the number of adverse events etc. Our whole system is built on it, from local auditing and Datix reporting, to CQC inspections. But counting the number of pressure ulcers for example, doesn’t really tell you about the standards of pressure ulcer care. I wanted to look at things differently; to focus more on the interventions and good practice that helps ke
  5. Community Post
    I am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focu
  6. Content Article
    The full impact of COVID-19 has not yet been realised, but what we do know is that we have been navigating with no roadmap or star to guide us. In terms of the three psychological phases of a crisis, we have worked through the initial state of ‘emergency’ where we have had (largely) shared goals and an urgency that made us feel energised, focused and even productive. However, this phase feels like it is in its descendancy and most of us are now in the next phase of ‘regression’ where the future feels uncertain and we have lost that sense of purpose. In my work with colleagues from across
  7. Content Article
    Ideas about resilient systems are now becoming better known in the healthcare community, but the most common question asked is “this is great but how do I put it into practice?” CARe QI provides the answers. The aim of CARe QI is to help people to apply the insights of resilient systems and ‘Safety II’ to the design, implementation and evaluation of quality improvement interventions. It is a structured collection of information, tools, guidance and documents that helps you to develop interventions to strengthen system resilience and in turn improve quality and safety. In the handbook you
  8. Content Article
    Key points Learning from Excellence (LfE) is a system for capturing examples of good practice in healthcare as a complementary approach to traditional incident reporting. The LfE philosophy proposes that learning from what works well in a system enables improvements in the quality and safety of the work, and the morale of staff performing it. LfE systems comprise simple reporting forms for peer-to-peer positive feedback with sharing of examples to enable wider learning. LfE reporting identifies excellence and learning opportunities in both process and outcome.
  9. Content Article
    This report, Hearing and Responding to the Stories of Survivors of Surgical Mesh, describes how restorative justice approaches were used to uncover the harms and needs created by surgical mesh use in New Zealand. The actions that consumers and healthcare stakeholders indicated would restore well-being, trust and safe healthcare in New Zealand are included. Skilled facilitators used restorative practices to create a safe space for consumers and health professionals to tell their stories. The same approach supported collaboration between multiple agencies so they could act for repair and p
  10. Content Article
    Having recently read a helpful and thought provoking summary on the varieties of human work by Steven Shorrock, I wanted to reflect on how the concepts he discussed apply to healthcare. I also wanted to look at how they might inform the thinking and actions of those working in patient safety roles in organisations where they do not have regular and direct contact with frontline staff. Shorrock discussed the four varieties of human work: work-as-imagined, work-as-prescribed, work-as-disclosed and work-as-done. All are instantly relatable to those who have worked in the NHS. Work-as-im
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