Jump to content

Search the hub

Showing results for tags 'Safety II'.


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
  • 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
    • 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 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 Learning news archive
    • 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
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous
    • Health care
    • Social care
    • Jobs and voluntary positions
    • Suggested resources

News

  • News

Categories

  • Files

Calendars

  • Community Calendar

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


Join a private group (if appropriate)


About me


Organisation


Role

Found 47 results
  1. Content Article
    This table originated in From Safety-I to Safety-II: A White Paper
  2. Event
    until
    This 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
  3. Content Article
    Safety-II is rapidly capturing the attention of the improvement world. However, there is very little guidance on how to apply it in practice. THIS Institute at the University of Cambridge have funded a study to explore how Safety-II (or Resilient Health Care) is being translated into healthcare policy and practice. Ruth is looking for people to take part in a one-off interview. She wants to speak to people who: work within the NHS to improve patient safety (whatever your role!) have or are applying Safety-II principles to improve safety in either maternity, A&E, ICU or anaesthetics (however successfully you feel you are doing it!) More information is attached. To get involved please contact Ruth R.M.Baxter@leeds.ac.uk and @RuthMBaxter
  4. Event
    until
    After 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: contact@humanisticsystems.com Register
  5. Content Article
    This article from Adrian Plunkett and Emma Plunkett, discusses some of the theoretical limitations of the prevailing approach to patient safety and introduce emerging, complementary approaches in this field of practice. Safety-II and resilience engineering represent a new paradigm of safety, characterised by focusing on the entirety of work, with a system-wide lens, rather than single incidents of failure. More overtly positive approaches are available, specifically focusing on success—both outstanding success and everyday success—including exnovation, appreciative inquiry, learning from excellence and positive deviance. These approaches are not mutually exclusive. The new methods described in this article are not intended as replacements of the current methods, rather they are presented as complementary tools, designed to allow the reader to take a balanced and holistic view of patient safety.
  6. Event
    until
    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 individual and team learning and how these can be positively managed? 4. The slow- and fast-moving sands of operations and environment change over time and their significance for safety. 5. How to pay as much attention to why work usually goes well as to why it occasionally goes wrong? 6. Understanding performance adjustments of individuals to get the job done. 7. The blessings and perils of performance variability. 8. Learning from data versus learning from observing. 9. Learning from differences in operations versus learning from monitoring for excrescences. 10. Can risk- and resilience-based concepts work together? 11. Does just culture matter for learning from success? 12. How to document explicitly, maintain current and use the information about success factors and safety barriers and shall this be a part of organisational SMS? Further information
  7. Content Article
    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.
  8. 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 prevention. The team that co-created the project includes academics, consumers, facilitators and New Zealand's Chief Clinical Officers. Formal research will evaluate the project next year and consider findings in the context of resilient healthcare systems
  9. 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) and provide feedback via completing the online survey or e-mailing Rose Jarvis before 28 February 2020. I would be interested to hear people's thoughts and feedback and any comments which people are happy to share which they've submitted via the online survey
  10. 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 focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
  11. 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 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.
×