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Found 29 results
  1. Content Article
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    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.
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    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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    The Flight Safety Foundation goal with this Seminar is to promote further globally the practical implementation of the concepts of system safety thinking, resilience and Safety II. There will be two sessions, one for each day, that will consist of briefings and a Q&A panel afterwards. The following themes are suggested for briefings and discussions for the Seminar 1.The limits of only learning from unwanted events. 2. Individuals’ natural versus organisations’ consciously pursued resilience. 3. How the ancient evolutionary individual instincts for psychological safety affect
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    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
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    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
  17. 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
  18. 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
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    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
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    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)
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    In this remarkable documentary, you can follow Kym Bancroft and Sidney Dekker in one organisation's (Urban Utilities) successful adoption and implementation of Safety Differently principles.
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