Search the hub
Showing results for tags 'Safety II'.
-
Content Article
Patient safety is a fundamental aspect of any healthcare system. Edmund Bailey and Mohammed Dungarwalla explore the development of patient safety both generally and in relation to dentistry over the past ten years. Other aspects of healthcare and various concepts are explained and described, including human factors, Safety I and Safety II, patient safety culture, managing patient safety incidents and the second victim concept, perfectionism and punishment myths, and hierarchy, along with wellbeing and support for practitioners. They bring together ten years of experience in patient safety related to dentistry and discuss this in the context of wider developments in patient safety, with reference to reports and policies that have influenced this field. The paper also includes helpful resources and suggestions to allow readers to discover more about patient safety in dentistry, and to examine the safety culture in their own organisations. They conclude by contemplating on what the next decade might bring.- Posted
-
- Dentist
- Organisational culture
- (and 3 more)
-
Content Article
Large Language Models (LLMs) are transforming the way in which people interact with artificial intelligence. This study explores how safety professionals might use LLMs for a FRAM analysis. The authors use interactive prompting with Google Bard / Gemini and ChatGPT to do a FRAM analysis on examples from healthcare and aviation. The exploratory findings suggest that LLMs afford safety analysts the opportunity to enhance the FRAM analysis by facilitating initial model generation and offering different perspectives. Responsible and effective utilisation of LLMs requires careful consideration of their limitations as well as their abilities. Human expertise is crucial both with regards to validating the output of the LLM as well as in developing meaningful interactive prompting strategies to take advantage of LLM capabilities such as self-critiquing from different perspectives. Further research is required on effective prompting strategies, and to address ethical concerns.- Posted
-
- AI
- Technology
-
(and 2 more)
Tagged with:
-
Content Article
In this podcast, Ricky Tenchavez shares his journey of implementing Scan4Safety at Doncaster and Bassetlaw NHS Trust. Discover how his clinical background and focus on staff engagement proved crucial to success, transforming initial resistance into enthusiastic adoption. Learn practical strategies for change management, from comprehensive staff training to building a champions network, and hear how the trust achieved rapid rollout across 28 theatres through effective communication and continuous support for staff. You can view some of the resources Ricky developed here scan4safety.nhs.uk/how-clinical-en…undation-trust/ Visit the Scan4Safety website scan4safety.nhs.uk/ A transcript of this episode is available. -
Content Article
For many years, standardisation has been regarded as the cornerstone of improving healthcare safety by increasing reliability and reducing variation. Yet, variation in the delivery of healthcare remains high and there are questions around the extent to which unquestioning application of standards supports safe care. Safety II theory views healthcare as a complex system with safety being regarded as the ability to succeed in varying conditions. At the heart of this theory lies the assumption that variation is not inherently risky, and that complex systems actually rely on adaptations in response to varying conditions to work effectively. This PhD from Deborah Clark aims to understand how and in what circumstance a flexible approach to safety management supports safety.- Posted
-
- Standards
- Safety management
-
(and 2 more)
Tagged with:
-
Content Article
Triage and clinical consultations increasingly occur remotely. In this study, published in BMJ Quality & Safety, Payne et al. aimed to learn why safety incidents occur in remote encounters and how to prevent them. They found that rare safety incidents (involving death or serious harm) in remote encounters can be traced back to various clinical, communicative, technical and logistical causes. Telephone and video encounters in general practice are occurring in a high-risk (extremely busy and sometimes understaffed) context in which remote workflows may not be optimised. Front-line staff use creativity and judgement to help make care safer. As remote modalities become mainstreamed in primary care, staff should be trained in the upstream causes of safety incidents and how they can be mitigated. The subtle and creative ways in which front-line staff already contribute to safety culture should be recognised and supported. -
Content Article
Safe and Sound is a podcast produced by the Barts Health Education Academy which aims to have honest, informative and educational discussions about patient safety and how it can be improved. In this episode, Dr Charlotte Hopkins, an HIV consultant who works in patient safety and Dr Annie Hunningher, a consultant anaesthetist and patient safety specialist, discuss the pros and cons between two different approaches to patient safety, Safety 1 and Safety 2.- Posted
-
- Anaesthesia
- Safety II
-
(and 1 more)
Tagged with:
-
Content Article
Simulation is traditionally used to reduce errors and their negative consequences. But according to modern safety theories, this focus overlooks the learning potential of the positive performance, which is much more common than errors. The authors of this article describe the learning from success (LFS) approach to simulation and debriefing. Drawing on several theoretical frameworks, they suggest supplementing the widespread deficit-oriented, corrective approach to simulation with an approach that focuses on systematically understanding how good performance is produced in frequent simulation scenarios.- Posted
-
- Training
- Simulation
-
(and 2 more)
Tagged with:
-
Content Article
The Resilient Health Care Society (RHCS) is a non-profit organisation registered in Sweden. The goal of the Society is to provide an international forum for coordination and exchange of principles, practices, and experiences, by bringing together researchers and professionals working with or interested in Resilient Health Care. Research and practice in Resilient Health Care aims to develop and promote practical solutions, based on a solid scientific foundation, to ensure that health care systems can perform as intended under expected and unexpected conditions alike. Links to some of their publications can be found below. Resilient Health Care, Volume 3 (2016) Reconciling Work-as-Imagined and Work-as-Done Edited ByJeffrey Braithwaite, Robert L. Wears, Erik Hollnagel Delivering Resilient Health Care (2019) Edited By Erik Hollnagel, Jeffrey Braithwaite, Robert L. Wears Working Across Boundaries (2019) Resilient Health Care, Volume 5 Edited By Jeffrey Braithwaite, Erik Hollnagel, Garth S Hunte Resilient Health Care (2021) Muddling Through with Purpose, Volume 6 Edited By Jeffrey Braithwaite, Erik Hollnagel, Garth Hunte- Posted
-
- Resilience
- Safety II
-
(and 2 more)
Tagged with:
-
Event
untilThis webinar offers a chance to explore the challenges and opportunities of the Safety-II approach with Mark Sujan, co-author of the BMJ Quality and Safety article ‘The problem with making Safety-II work in healthcare.’ In 2020 Q’s ‘Organisational Resilience & Safety-II’ Special Interest Group (SIG) ran workshops to share adaptations being made to address the emerging COVID-19 crisis. Many solutions were shared but significant challenges were identified. In this webinar we will build on the insights found and explore the arguments in the recent BMJ Quality and Safety article, ‘The problem with making Safety-II work in healthcare.’ We will be joined by the paper’s co-author Mark Sujan, as we lean into the promises and potential of Safety-II, and what gaps we need to bridge to revolutionise our understanding of what safety truly is in health care. The one hour webinar will: Outline the challenges and opportunities of a Safety-II approach Allow you to hear from peers implementing Safety-II Provide you with an opportunity to discuss your experiences of Safety-II in small groups Register for the webinar -
Event
untilAfter two years with virtual workshops due to the Covid-19 pandemic, we are pleased to announce that the fifth International Workshop on Safety-II in Practice will be organised on site in Edinburgh, Scotland on September 7-9, 2022. The Workshop is organised by FRAMsynt. The workshop will begin with an optional half-day tutorial on Safety-II in Practice in the afternoon of September 7 (1330-1730 BST), and continue with two days of meetings and discussions from September 8 (0830-1700 BST) to September 9 (0830-1500 BST). There will be a walking tour of Edinburgh old town (hosted by Steven Shorrock) and a dinner on the evening of September 8 for those who wish to join. Aim of the workshop The aim of the workshop is to share experiences from existing and/or planned applications of a Safety-II approach in various industries and practices. The workshop will give the participants an opportunity to present and discuss problems encountered and lessons learned – good as well as bad, practical as well as methodological. The workshop is a unique opportunity for safety professionals and researchers to interact with like-minded colleagues, to debate the strengths and weaknesses of a Safety-II approach, and to share ideas for further developments. The guiding principle for the workshop is “long discussions interrupted by short presentations”. In order to achieve this, the number of participants will be limited to 60 – first come, first served. Participation The workshop is open to everyone regardless of their level of experience with Safety-II. It will address the use of Safety-II in a variety of fields and for purposes ranging from investigations, performance analyses, organisational management and development, individual and organisational learning, and resilience. The workshop will provide a unique opportunity to: Discuss and exchange experiences on how a Safety-II approach can be used to analyse and manage complex socio-technical systems. Receive feedback on and support for your own Safety-II projects and ideas. Learn about the latest developments and application areas of Safety-II. Develop a perspective on the long-term potential of a Safety-II approach. Discussion topics, presentations and papers You can contribute actively to the workshop by submitting proposals for: Topics or themes for panel discussions (preferably with a presentation or introduction, but open suggestions of themes are also welcome). Presentations of ongoing or already completed work in industry and/or academia. Ideas that you would like to get a second opinion on. Questions or issues that you have been wondering about and would like to hear more about. The relevance of a Safety-II perspective for individual and organisational learning. The strategic management of Safety-II: how to introduce changes to routines and daily practice. For each type of proposal, please provide a short abstract (about 100 – 200 words, but even less if need be) with a summary of what you would like to present or discuss and how you want to be involved. All proposals will be reviewed and comments to the submitters will be provided. Please submit your proposed contribution to: [email protected] Register- Posted
-
- Safety II
- System safety
-
(and 2 more)
Tagged with:
-
Content Article
Gavin Portier is Head of Nursing Quality at Barnsley Hospital NHS Foundation Trust. In this interview, Gavin explains how his approach to auditing has moved beyond measuring negative outcomes, instead focusing on standards of care. 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 keep patients safe. Where did you start? We started with pressure ulcer reduction. Our Tissue Viability team and I looked at the learning from Root Cause Analyses and worked together to create a list of all of the things we can do to help prevent pressure ulcers. Skin assessments, pillow positioning, moving patients etc. If we ticked every box for every patient, would we prevent pressure ulcers altogether (unless the patient doesn’t follow the advice)? I took this list and worked with the digital app company, Perfect Ward to build a simple-to-use auditing tool. It allows us to measure safety by our standards of care and interventions rather than counting negative outputs. If our standards of care are high and a lot of people are still getting pressure ulcers, we have assurance on the standard of care being delivered. How did you implement the pressure ulcers audit? Once we had created the list of standards and preventative measures, we used the app to do an audit of around 35% of patients on each ward. At the start of the project, we found that teams were on average hitting 64% of the standards. The digital app provides a performance rating system, with red with red (less than 70%), amber (greater than 70% but less than 90%) and green (90% or more). The performance of the team against these ratings dictate how we would support each team moving forward. For example, if an audit showed a team to be performing at the lowest level (red), we made a commitment to support them on a weekly basis until they were performing at the highest level (green). How have staff responded? Staff have responded really well. This system provides recognition, and credit where credit is due. It can help staff to feel confident when they are providing high standards of care and to know that they are doing the right thing for the patients. Where there is room for improvement, the Perfect Ward app makes it is easy to see where the gaps in the delivery of interventions exist so they can be tackled. The tissue viability nurses are there to support, coach and to help problem solve. There may be certain interventions that are consistently missed which can sometimes be a sign that the wider organisation needs to help solve the issue. Safety is a shared responsibility, and we need to make sure we have the systems in place to support success. What support have you needed along the way? It’s really important to have passionate people who understand and believe in this approach to auditing. You need to have an Executive Team who are prepared to look at measuring outcomes differently. I’m lucky, our Director and Deputy Director of nursing are very supportive. It’s also important to acknowledge that it is not a silver bullet; change takes time. That can be frustrating for some people who want to see results quickly. It’s taken a year but teams are now hitting on average 94% of the standards set out by the auditing tool, and we are starting to see decreases in category 2 pressure ulcers (per 1000 bed days) since June 2020. What have you learnt? It has been really important to constantly engage staff and build good relationships, to make sure we understand everyone’s competing priorities. The approach has been a great enabler for quality improvement methodology, empowering teams to find their own solutions and really own the results. What’s next? This approach to auditing is not rocket science. It can be used to raise standards of care in most circumstances within health and social care – without focusing on the negatives. We have successfully applied it to both pressure ulcer and falls prevention at Barnsley and just started on nutrition and hydration. In the future I’d like to see it used in other areas, to identify what excellent dementia care in hospitals looks like for example. It could also be used to ensure that staff have a good understanding of the Mental Capacity Act and safeguarding processes. Or to make sure patients are being well-fed. It really is just a blueprint that can be used to raise standards of care, and safety in any circumstance. Final thoughts? I personally don’t like to look at my work as reducing harm. I prefer to look at it in terms of improving the standards of care we give our patients. The difference is important. Photograph of the Tissue Viability Team. Above is an example of a checklist used for pressure sores. The graph above shows the trust average on delivery of the pressure ulcer prevention interventions across adult inpatient wards over a 12 month period. The 'distribution of score' graph above shows the percentages scored across the adult inpatient wards for each month over a 12 month period. This graph shows more areas achieving 90% (or more) and fewer scoring 70% or less as time has progressed. -
Content Article
A sub-group of rare but serious patient safety incidents, known as ‘never events,’ is judged to be ‘avoidable.’ There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of ‘preventable harm’ with zero tolerance ‘never events,’ especially around the lack of evidence for such harm ever being totally preventable. Bowie et al. consider whether the ideal of reducing preventable harm to ‘never’ is better for patient safety than, for example, the goal of managing risk materialising into harm to ‘as low as reasonably practicable,’ which is well-established in other complex socio-technical systems and is demonstrably achievable. They reflect on the ‘never event’ concept in the primary care context specifically, although the issues and the polarised opinion highlighted are widely applicable. Recent developments to validate primary care ‘never event’ lists are summarised and alternative safety management strategies considered, e.g. Safety-I and Safety-II.- Posted
-
- Never event
- Patient safety incident
-
(and 2 more)
Tagged with:
-
Content Article
Learning from excellence in healthcare
Patient Safety Learning posted an article in Implementation of improvements
Learning from everyday work means learning from all activities regardless of the outcome. But when things go well, this is typically just gratefully accepted, without further investigation. ‘Learning from Excellence’ is changing this, as Adrian Plunkett and Emma Plunkett describe in this 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. LfE is aligned with aspects of appreciative inquiry and Safety-II.- Posted
-
- Implementation
- Patient safety incident
- (and 5 more)
-
Content Article
In this blog, Farrah Pradhan, Project Manager for Clinical Quality, Education and Projects at RCOG, describes her work with maternity professionals, namely obstetricians, and through undertaking an MSc in Patient safety. Farrah’s focus was on their 'work as done' to see if the concepts of Safety-II (capability mindfulness and resilience engineering) helped them to work more safely. ‘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 because clinicians are flexible and can vary their performance that allows the system to function albeit with acceptable or adverse outcomes. As healthcare is intractable (not easily controlled), performance adjustments are vital. Things often go well because obstetricians make sensible adjustments in response to the situations to ensure safety, often within a highly pressurised environment. These adaptations and performance variables, under complex circumstances, are not well understood. Combining the concepts of capability mindfulness, positive deviance and resilience engineering as the principles of safety-II and understanding the 'work as done' and the performance variability of obstetricians’ (that results in good or successful outcomes), may bring insights that can be used to help build adaptive capacities and capabilities in obstetricians when working in unpredictable and unanticipated stressful clinical environments. Compassion against a backdrop of complexity My first encounter with an obstetrician was over 21 years ago when I was pregnant with my first baby. The attention and kindness that I received by the obstetrician and his team were incredible; I was cared for with gentleness and understanding. He spoke to me with compassion, and in moments of delivering uncertain news, he placed his hand on my shoulder, showing his empathy for my circumstances. I saw him regularly until it was time for my baby to be born, twelve weeks early. This experience, although very traumatic, opened my eyes to a caring profession that surpassed any expectation that I could ever have imagined. When I came to work at the Royal College of Obstetricians and Gynaecologists nearly seven years ago, I had the privilege of witnessing more of these encounters. I visited maternity units, listening and watching obstetricians and their colleagues work tirelessly for women and their babies against a backdrop of complexity and variation. Intrigued by this, I decided to pursue a Master’s degree in Patient Safety. I wanted to understand what it was that gave obstetricians this skill; to work effectively while maintaining a constant awareness of situations, identifying and managing emergencies and providing day-to-day care, all at the same time. Proactive safety management My dissertation (under the supervision of Professor Suzette Woodward) focused on obstetricians’ use of proactive safety management concepts (termed Safety-II). Taking a safety-II approach includes looking at 'work as done’ [1]. These are the adjustments, compromises, workarounds, actions and decisions that obstetricians make, to meet the needsof the women they care for. Obstetricians have to make prompt decisions, organise multiple activities and co-ordinate care rapidly, all within an already complex system. ‘Work as done’ is achieved because of a combination of expertise, clinical decisions, experience and tacit knowledge and because obstetricians vary their performance, depending upon changing circumstances, that allows the system to function. Reliability, adjustment, and safety Studying ‘work as done’ brought insights into how obstetricians build adaptive capacities when working in complex settings. This adaptation is an essential factor in the interaction between complex infrastructures and human behaviour. Because healthcare is intractable, clinicians are relied on to adjust to situations (emergency cases, staff shortages, high patient numbers etc.) to create safe outcomes, as well as recover from unexpected events. Reliability is a necessary requirement of safety and is concerned with the likelihood of occurrence of failure [2]. Clinicians are vital to creating high reliability and a resilient system. Through my research with obstetricians, I found that they successfully demonstrated their adaptive capabilities to respond to unforeseen, unpredictable and unexpected demands and recover from high-risk situations, also known as resilience engineering [3]. The ability of obstetricians and their teams to be in a state of constant alertness, sensitive to changes in women’s conditions, continually re-evaluate their safety supposition, and respond as appropriate, is a key resilient strength that was evident. It also requires an organisational culture that nurtures a climate of trust and respect. The importance of culture and relationships During interviews, obstetricians described the importance of trusting relationships, which fostered excellence in team working, and the ability to be collectively and consciously alert to risks and mitigations. Overall, they demonstrated excellent leadership attributes, valued safe care centred on the woman and her baby, good working relationships and the feeling that they made a positive difference. "It was having the willingness to step in and take that level of responsibility in that situation. … it was also familiarity with the team and communication with the team, and drawing in the expertise of cardiologists and the anaesthetist so that we did have a cohesive joined up plan that we'd all agreed on and we'd communicated out to everyone." (Consultant Obstetrician, Manchester) “It’s about staying calm, understanding what the whole situation is, … it's about gaining the trust of the woman and the staff, gaining the trust of the staff is much easier if it's a team that you know, who you've worked closely with, who know you as well, because they know what your skill set is.” (Consultant Obstetrician, London) Improving maternity safety – some final thoughts My research concluded that a systems approach to maternity safety including human factors and safety management must be adopted to understand 'work as done'. Safety can be improved through ‘learning from excellence’ as a way of cultivating habits in focussing on the activities that promote good outcomes, hence strengthening resilience as well as continuing to learn from the inevitable errors. I suggested using human reliability analysis, a technique looking at a process of care and systematically examining the process, to pinpoint and foresee possible failure points to proactively manage safety within a unit. Excitingly, the NHS Patient Safety Strategy [4] is striving to embed safety-II principles, and healthcare regulators are considering how proactive safety management can be measured and developed as part of their inspection frameworks. Indicators for resilience engineering [5] are also emerging which will assist with assessing a resilient work environment and provide metrics for safety measurement. You can read Farrah's full dissertation paper in the document attached towards the end of this webpage. References 1. Hollnagel E, Braithwaite J. From Safety-I to Safety-II: A White Paper. The Resilient Health Care Net; 2015. 19 2. Vincent C. The measuring and monitoring of safety. UK: The Health Foundation; 2013. 3. E. Hollnagel JB, R Wears. Resilient Health Care: Ashgate Publishing Limited; 2013. 225 p. 4. NHS Improvement. The NHS Patient Safety Strategy Safer culture, safer systems, safer patients. July 2019. Available from https://www.england.nhs.uk/wp-content/uploads/2020/08/190708_Patient_Safety_Strategy_for_website_v4.pdf 5. Ranasinghe U, Jefferies M, Davis P, Pillay M. Resilience Engineering Indicators and Safety Management: A Systematic Review. Saf Health Work. 2020;11(2):127-35.- Posted
-
- Obstetrics and gynaecology/ Maternity
- Decision making
- (and 4 more)
-
Content Article
In this 30 minute film, Adrian Plunkett introduces the concept and history of learning from from excellence. Content also includes: Safety-II Positivity language Negativity bias.- Posted
-
- Safety II
- Organisational culture
-
(and 1 more)
Tagged with:
-
Content Article
This blog looks at how positive reporting of good practice and success can help support health systems and organisations in their journey to become highly reliable and improve patient safety. This is part of a joint series of blogs and video conversations exploring how we can improve patient safety through the application of principles of high reliability in healthcare, made collaboratively by Patient Safety Learning and RLDatix. 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- Posted
-
1
-
- Organisational culture
- Patient safety incident
- (and 3 more)
-
Content Article
The purpose of this guide from NHS Education for Scotland is to help people working in the health and social care ecosystem capture valuable practice and improvements made during their response to COVID-19. The aim is to contribute to organisational change at a policy, strategic and operational level. If left too late, there is a real danger that positive change is not documented and will be lost as the health system emerges from the pandemic. -
Content Article
Screening incidents: thinking differently
PatientSafetyLearning Team posted an article in Improving patient safety
In this blog, Suzette Woodward, an international expert on patient safety, advises Public Health England on its review of the screening incident guidance, setting out her thoughts on how learning from safety incidents could be strengthened. -
Content Article
Recently, there has been a lot of interest in some ideas proposed by Prof. Erik Hollnagel and labeled as “Safety-II” and argued to be the basis for achieving system resilience. He contrasts Safety-II to what he describes as Safety-I, which he claims to be what engineers do now to prevent accidents. What he describes as Safety-I, however, has very little or no resemblance to what is done today or to what has been done in safety engineering for at least 70 years. In this paper, Prof. Nancy Leveson, Aeronautics and Astronautics Dept., MIT, describes the history of safety engineering, provides a description of safety engineering as actually practiced in different industries, shows the flaws and inaccuracies in Prof. Hollnagel’s arguments and the flaws in the Safety-II concept, and suggests that a systems approach (Safety-III) is a way forward for the future.- Posted
- 1 comment
-
1
-
- System safety
- Safety II
-
(and 2 more)
Tagged with:
-
Content Article
Ben Watson is a Strategy Implementation and Quality Improvement (SIQI) Manager in the Scottish Ambulance Service. He is currently responsible for supporting operational services in the West of Scotland, to see how they can improve patient care, existing processes and develop new ways of working that benefit both staff and patients. In this interview, Ben explains why they’ve started collecting positive feedback through a peer-to-peer system called GREATix.- Posted
-
- Feedback
- Staff engagement
-
(and 1 more)
Tagged with:
-
Content Article
Intensive Care bed space orientation
Claire Cox posted an article in Other health and care software
This interactive orientation of an Intensive Care Unit (ICU) bed space, created by the London Transformation and Learning Collaborative, is ideal for healthcare professionals new to the ICU environment. It allows you to explore the risks and demonstrated the safety check required to keep patients safe in the ICU. This application is best used with a smart phone, but can be used on a computer.- Posted
-
- ICU/ ITU/ HDU
- Simulation
-
(and 1 more)
Tagged with:
-
Content Article
GREATix: Reporting the positive
PatientSafetyLearning Team posted an article in Safety culture programmes
The Scottish Ambulance Service has recently launched a positive reporting scheme called GREATix. GREATix is a peer-to-peer tool for recognising and learning from positive feedback in the workplace. Feedback will be used to pass on words of gratitude and identify improvement strategies. -
Content Article
The Lilypond is a new conceptual model to describe patient safety performance. It radically diverges from established patient safety models to develop the reality of complexity within the healthcare systems as well as incorporating Safety II principles. There are two viewpoints of the Lilypond that provide insight into patient safety performance. From above, we are able to observe the organisational outcomes. This supersedes the widely used Safety Triangle and provides a more accurate conceptual model for understanding what outcomes are generated within healthcare. From a cross-sectional view, we are able to gain insights into how these outcomes come to manifest. This includes recognition of the complexity of our workplace, the impact of micro-interactions, effective leadership behaviours as well as patterns of behaviour that all provide learning. This replaces the simple, linear approach of The Swiss Cheese Model when analysing outcome causation. By applying the principles of Safety II and replacing outdated models for understanding patient safety performance, a more accurate, beneficial and respectful understanding of safety outcomes is possible.- Posted
-
- Safety II
- Quality improvement
- (and 3 more)
-
Content Article
Annual SHOT report 2019
Patient Safety Learning posted an article in Other
SHOT (Serious Hazards of Transfusion) is the UK's independent professionally led haemovigilance scheme. This year’s Annual SHOT Report looks back at trends and data for the last calendar year, but also highlights several very important messages for us in the present extraordinary times. The data in the report come from across the UK and include material from all areas of healthcare where transfusion is practised. As in previous years, it is certain that under-reporting is significant. Reporting rates in some of the higher usage Trusts/Health Boards vary twentyfold. Given the cultural, resource and procedural similarities of these organisations, it is highly unlikely that the error and mishap rate varies by anything like this much, so reporting rates are likely to play a large part. One area where this is likely to have greatest impact is in the reporting of near misses, the most fertile learning area. The leading causes of transfusion-related incidents are, again this year, ‘human factors’ related, with procedural failures and flawed decision-making contributing in large measure. While decision support tools and information technology have gained some traction, and continue to help us progress in these areas, their universal adoption remains some way off. Until these are more widespread, we continue to rely on education and peer pressure to encourage best practice. A ‘human factors’ approach is key to understanding why errors and accidents continue to occur, despite, in many cases, adequate training, knowledge, expertise and currency. Those areas of hospitals which are under greatest stress and pressure, for example, emergency departments, continue to report a year on year increase in errors. Despite this, transfusion remains very safe indeed,with the risk of serious harm being 1 in 17,884 and death 1 in 135,705 transfused components in the UK.- Posted
-
- Medicine - Haematology
- Blood / blood products
- (and 3 more)
-
Content Article
This info-graphic by the Faculty of Pain Medicine is a safety checklist for Interventional Pain Procedures under local anaesthesia or sedation. This has been adapted from the World Health Organization surgical checklist.- Posted
-
- Checklists
- Medication
-
(and 2 more)
Tagged with: