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Found 161 results
  1. Content Article
    A new MIT study identifies six systemic factors contributing to patient hazards in laboratory diagnostics tests. By viewing the diagnostic laboratory data ecosystem as an integrated system, MIT researchers have identified specific changes that can lead to safer behaviours for healthcare workers and healthier outcomes for patients.
  2. Content Article
    A series of LinkedIn articles on systems thinking from Phil Evans, Independent HealthTech Consultant.
  3. Content Article
    In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk.  In part 1 of this blog series, Norman suggested that measuring safety is problematic because the inherent variability in any system is largely invisible. Unfortunately, what we call safety is largely a function of the risks arising from that variability. In this blog, Norman explores how error might offer a pointer to where we might look. 
  4. Content Article
    *Trigger warning: This report contains accounts of bullying behaviours and consequences and may trigger those who have experiences of bullying. The Say No to Bullying in Midwifery report comprises hundreds of accounts, ranging from students, newly qualified and senior midwives, heads of midwifery, maternity support workers and more. It aims to publicise and share concerns they have raised online. In the numerous accounts shared all areas of the system from CQC, CEO, HR, midwifery management, universities and the unions are described as being complicit, inadequate, disinterested and even corrupt. Accounts also refer to: Unsafe work environments Exit interviews not being performed, recorded or acted upon Staff not being valued Whistle-blowers being demonised until they leave Health and safety issues and truly evidence-based practice ignored with no lessons learned. To order your copy, follow the link below.
  5. Content Article
    Inpatient falls are one of the most common patient safety incidents reported in rehabilitation wards in Australia and can result in serious adverse patient outcomes, including permanent physical disability and occasionally death. Camden Hospital in Australia implemented a multidisciplinary review meeting (Safety Huddle) following all inpatient falls and near miss falls, which developed strategies in consultation with the patient to prevent the incident from reoccurring.
  6. News Article
    Racism is a significant issue affecting recruitment, retention, and patient care. With this in mind, the Royal College of Psychiatrists launched the Act Against Racism campaign, offering guidance and actions to combat racism in the workplace for better staff well-being and patient care, writes Adrian James In June, HSJ revealed that mental health trusts in England are among the biggest users of locum doctors in the NHS. With one in seven medical posts in mental health trusts vacant, many providers now rely on locum doctors to deliver essential services to patients. Read full story Source: HSJ, 9 August 2023
  7. Content Article
    These new updated guidelines, produced in collaboration between the Healthcare Infection Society and The European Society of Clinical Microbiology and Infectious Diseases, used NICE-accredited methodology to provide further advice on which practices in the operating theatre are unnecessary. The guidelines are intended for an international audience. Specifically, they discuss the current available evidence for different rituals that are commonplace in the operating theatre and highlight the gaps in knowledge with recommendations for future research.
  8. Content Article
    In this article Steven Shorrock argues that understanding the complexities and nuances of human work is critical if we are to improve how work really works. In healthcare, as clinicians and other healthcare professionals navigate their roles, they encounter a diverse array of situations that create goal conflicts, dilemmas and other challenges. One way to explore these is via micro-narratives. These are short stories based on personal observations and experiences. One method to capture these is via simple written postcards. Postcards from Work (Healthcare Edition) delves into these experiences. A sample of the cards is shown within the article.
  9. Community Post
    NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks
  10. Content Article
    I this article for the Institute for Health Improvement, Rachel Hock highlights some of the safety concerns and issues that can arise through discriminatory attitudes and stigma associated with weight. 
  11. News Article
    Healthcare leaders have written an open message to NHS staff, drawing attention to “the dangerous level” of abuse many are confronted with, “simply for going to work”. In the message, more than 40 NHS leaders in London said that every year “tens of thousands” of NHS staff are “confronted with violence and aggression from patients”. “Now, the abuse is at a dangerous level, with many of our once hailed heroes fearing for their safety,” they said. “We, leaders of the NHS in London, are speaking with one voice to say that aggression and violence towards our staff will not be tolerated.” Signatories include Andrew Ridley, the NHS England London interm regional director, integrated care system leaders, leaders from general practice and community pharmacy, and many trust bosses from the capital, including Central and North West London FT chief executive and national director for mental health Claire Murdoch. The message thanked NHS staff for continuing to care for people and encouraged the reporting of “all forms of verbal and physical abuse from patients, their families and friends so that we may take action”. They also sent a message to patients and their families: “We will strive to do our best for you and your loved ones. People who are most unwell do need to be seen most urgently, but all our patients are important to us and will receive the care needed. While we are thankful for the support shown by so many, to those who show violence and aggression let it be known: abusing our staff is never ok.” Read full story (paywalled) Source: HSJ, 21 March 2022
  12. News Article
    Specialist nurses at an NHS hospital have been told they may be taken off clinical shifts to help clean wards, it has emerged. Bedfordshire Hospitals NHS Foundation Trust has said it asked nursing staff to help clean wards as the hospital faced the “most challenging circumstances” it has ever faced. Clinical specialist nurses, who are advanced nurses and can usually have hundreds of patients under their care, were among those asked to spend entire shifts helping other wards “cleaning”, “tidying” and “decluttering”. The news has prompted criticism from unions, however, multiple nurses have reported that the requests happen “often” during winter. Alison Leary professor of healthcare and workforce at South Bank University warned that asking specialist nurses to drop their work was “very risky”. She said: “This problem keeps cropping up-as soon as there is pressure on wards they are expected to abandon their patients. It usually happens in winter and so it’s concerning that it has now started to happen in summer. “This also shows very little respect for nursing generally and will not help retention. Trusts need to plan workforces accordingly and should ensure they have the right amount of cleaning, administrative and housekeeping staff-all staff groups which contribute to patient safety and care quality." Read full story Source: The Independent, 8 August 2022
  13. Content Article
    This newsletter from Psychological Safety, provides an overview of the two different concepts of Safety I and Safety II. Follow the link at the bottom of the page to read the article in full. 
  14. Content Article
    In this article, published by the Betsy Lehman Center, the author reviews Dr. René Amalberti's work which explains in detail why and how groups of workers can fall into risky habits over time.
  15. News Article
    A boss at a trust which was heavily criticised in a damning report says patients have lost confidence in the care they provide. Raymond Anakwe, executive director of East Kent Hospitals Trust, said regaining patient trust would be "possibly the largest challenge". He was speaking at a board meeting two weeks after a review found a "clear pattern" of "sub-optimal" care. Mr Anakwe said: "The reality is we have lost the confidence of our patients." He also said the trust has lost the confidence "of our local community and sadly also many staff". The trust's chief executive, Tracey Fletcher, told the meeting that she believed many staff thought "enough is enough", and that the trust has to be "brave" if it's to move forward. Stewart Baird, a non-executive director, said: "I think it's clear the buck stops here with the people sat round this table, and where there are bad behaviours in the trust, it's because we have allowed it. "Where people don't feel able to speak up, it's because we have not provided an environment for them to do that." Read full story Source: BBC News, 3 November 2022
  16. News Article
    Nurses at a hospital run by a major private healthcare provider have been threatened with disciplinary action after apparently refusing to treat coronavirus patients, according to a leaked email seen by HSJ. The email was sent on Sunday by a senior matron at Nuffield Health’s Cheltenham Hospital, which has been made available to the NHS during the COVID-19 outbreak. She said: “I’m hoping to get another undisturbed day as I’m going to have to formally take on everyone who won’t help on the C19 side." “Unfortunately, it will be a disciplinary matter and referral to the [Nursing and Midwifery Council]. I really don’t want to go down that route but they’re giving me little choice.” It is not clear why staff had refused to help with COVID-19 work, but one staff member who spoke with HSJ said nurses had objected to working without personal protective equipment. A spokesman for Nuffield Health said: “We can categorically state that we have been provided with a full supply of PPE from the local NHS trust so that all members of the team are protected when they treat COVID-19 patients. The team has also been given the appropriate training to ensure they can carry out their roles safely.” Read full story Source: HSJ, 14 April 2020
  17. News Article
    Matt Morgan, an intensive care doctor, describes in this Guardian article how his ICU are preparing for the coronavirus crisis. "ICUs are as prepared as they can be. Locally business as usual has made way for preparations for caring for high numbers of patients. We are finding every ventilator we may have and identifying every suitably qualified member of staff. We will work together to fill gaps as best we can. There’s a sense of anticipation about what the next eight, 10, 12 weeks are going to bring in terms of work. Anyone who works in healthcare is also a mum, dad, daughter, brother, son. We want to give everything to saving lives and work and care, but equally we’re thinking about the logistics of personal lives and elderly relatives too." Matt says his worst nightmare is having insufficient workforce and equipment to meet patient needs. Whether or not that will come to fruition is tough to predict. He also says that his ICU has a psychologist who’s doing a huge amount of thinking about putting in place wellbeing resources for staff who might be in moral distress after having to prioritise one patient over another. "If there are 500 patients and only 200 ventilators then that’s when we need national guidance from the government and other bodies. It can’t be up to individual doctors. The age of playing God is long behind us. The question is who should we be making decisions with: the public, government or within the profession?" Read full story Source: The Guardian, 13 March 2020
  18. News Article
    Five years after launching a plan to improve treatment of black and minority ethnic staff, NHS England data shows their experiences have got worse. Almost a third of black and minority ethnic staff in the health service have been bullied, harassed or abused by their own colleagues in the past year, according to “shameful” new data. Minority ethnic staff in the NHS have reported a worsening experience as employees across four key areas, in a blow to bosses at NHS England, five years after they launched a drive to improve race equality. Critics warned the experiences reported by BME staff raised questions over whether the health service was “institutionally racist” as experts criticised the NHS “tick box” approach and “showy but pointless interventions”. Read full story Source: The Independent, 18 February 2020
  19. News Article
    Today the results of the National NHS Staff Survey 2019 are out. This is of the largest workforce surveys in the world with 300 NHS organisations taking part, including 229 trusts. It asks NHS staff in England about their experiences of working for their respective NHS organisations. The results found that 59.7% of staff think their organisation treats staff who are involved in an error, near miss or incident fairly. While an improvement on recent years (52.2% in 2015) work is needed to move from a blame culture to one that encourages and supports incident reporting. It also found that 73.8% of staff think their organisation acts on concerns raised by patients/service users. It is vital that patients are engaged for patient safety during their care and there is clear research evidence that active patient engagement helps to reduce unsafe care. Patient Safety Learning has recently launched a new blog series on the hub to develop our understanding of the needs of patients, families and staff when things go wrong and looking at how these needs may be best met.
  20. News Article
    A young woman was left with a retained foreign object, after surgery in an India hospital. A checklist could have avoided her death. The response from the health officials was: “We have issued a show-cause notice to the staff seeking an explanation. We will initiate departmental action based on their replies and finding of our inquiry.” In the fields of healthcare quality and patient safety, such punitive measures of “naming and shaming” have not worked. T.S. Ravikumar, President, AIIMS Mangalagiri, Andhra Pradesh, moved back to India eight years ago with the key motive to improve accountability and safety in healthcare delivery. He believes that we have a long way to go in reducing “preventable harm” in hospitals and the health system in general. "We need to move away from fixing blame, to creating a 'blame-free culture' in healthcare, yet, with accountability. This requires both systems design for safe care and human factors engineering for slips and violations". "Providing safe care without harm is a 'team sport', and we need to work as teams and not in silos, with mutual respect and ability to speak up where we observe any deviation or non-compliance with rules, says Ravikumar. Basic quality tools and root-cause analysis for adverse events must become routine. Weekly mortality/morbidity conferences are routine in many countries, but not a routine learning tool in India. He proposes acceleration of the recent initiative of the DGHS of the Government of India to implement a National Patient Safety Framework, and set up an analytical “never events” or sentinel events reporting structure. Read full story Source: The Hindu, 12 January 2020
  21. News Article
    Hundreds of sexual assaults are reported each year on mixed-sex mental health wards in England, HSJ can reveal, highlighting the urgent need for investment to improve facilities. New figures obtained by HSJ show there have been at least 1,019 reports of sexual assaults between men and woman on mixed wards since April 2017 to October 2019. This compares to just 286 reports of incidents on single-sex mental health wards over the same period. Of those reports made on mixed-sex wards, 491 were considered serious enough to refer to safeguarding, and 104 were reported to the police. The level of incidents still being reported suggests patients are not being protected from sexual assault on mixed wards, despite the issue being highlighted by several national reports in recent years. Read full story (paywalled) Source: HSJ, 7 January 2020
  22. Content Article
    Raising a concern is not always easy, but it is the right thing to do. It is about safeguarding and protecting, as well as learning from a situation and making improvements. This guide by the Royal College of Nursing is to help nurses, nursing associates, students and healthcare support workers based in the NHS and independent sector.
  23. Content Article
    Current research suggests that staff mindfulness practices can contribute to better safety outcomes. Researchers at the University of Houston have conducted a systematic review of studies that assess the relationship between mindfulness and safety at work. The study suggests that: mindfulness training does not need to be lengthy or frequent to have a significant impact on workplace safety different mindfulness training techniques are better suited to specific industries such as healthcare and the military.
  24. Content Article
    It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."
  25. Content Article
    Every year, avoidable harm leads to the deaths of hundreds of thousands of patients, each an unnecessary tragedy. Despite many people doing good work to improve patient safety, this remains a persistent problem. At the recent Future of Hospitals event from Health Plus Care Online, Helen Hughes, Patient Safety Learning's CEO, and Donna Prosser, Chief Clinical Officer of the Patient Safety Movement, consider the need for patient safety to be a core purpose of healthcare and how we can best achieve this. They also discuss whether patient safety can become a social movement - uniting clinicians, patients, leaders, policy-makers and communities.
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