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Found 530 results
  1. Content Article
    A common administrative framework of healthcare involves focus upon costs, quality and patient satisfaction—this is known as The Triple Aim.  However, this framework does not allow the experience and human factors of providing care to be integrated into high-level decision making. This report describes the process of transition from The Triple Aim to The Quadruple Aim administrative framework of healthcare delivery at the University of Rochester Medical Center, which resulted in an integrative model of patient safety and clinician wellbeing. Developing the fourth aim of improving the experience of providing care was widely accepted and aligned with other health system goals of optimisation of safety, quality and performance by applying a human factors/ergonomic (HFE) framework that considers human capabilities and human limitations.
  2. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Joy talks to us about why we need to reduce the use of restrictive practices in healthcare, the role of research in identifying unsafe practices and how the Restraint Reduction Network shares and helps organisations implement safer approaches to care.
  3. Content Article
    The Patient Safety Management Network (PSMN), created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. Claire Cox, Quality Patient Safety Lead, King's College Hospital NHS Foundation Trust, looks at how the Network has evolved over the last two years, its achievements and its aims going forward. 
  4. Content Article
    This case study shares learning from the approach to retention at University Hospitals Birmingham. In particular it highlights how the trust adopted a new approach to organisational culture and staff engagement which has had a positive impact on staff retention. Effective use of data is a key element and has played a key role in making progress. The trust still faces challenges but has improved retention and is moving in right direction.
  5. Content Article
    Are you a surgical doctor working in the NHS? Could you spare 1 hour of your time to share your insights and help researchers explore psychological safety? Shinal Patel-Thakkar, a trainee Clinical Psychologist, is seeking participants for a qualitative research study into psychological safety in surgical environments. In this interview she tells us more about the study, how people can register their interest, and provides reassurance that confidentiality will be maintained.
  6. Content Article
    In this interview for inews, Professor Ted Baker, Chair of the new Health Services Safety Investigations Body (HSSIB), talks about the role of HSSIB in identifying system-wide safety issues in the NHS. He discusses why we need new approaches to tackling patient safety problems and outlines the importance of considering how the wider system leads to human error. He also talks about the impact of bullying on NHS staff, describing his own experiences as a junior doctor, which nearly led him to give up his career. He also describes the vital role of whistleblowers in making changes that genuinely improve patient safety, highlighting the problems currently facing staff who speak up for patient safety.
  7. Content Article
    Leadership in a safety culture environment is essential in avoiding patient harm. However, leadership in surgery is not routinely taught or assessed. This study aimed to identify a framework, metrics and tools to improve surgical leadership and safety outcomes. It identified three areas of leadership needed to build a culture of safety in surgery: Control risk (risk management) Drive progress (opportunity management) Rally support for the mission (people management) A leadership assessment tool (SLAM) was developed to provide objective metrics of surgical leadership behaviours based on nine key performance indicators.
  8. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Kevin talks to us about the role research plays in improving staff and patient safety. He explains how his own research has uncovered the extent of violence experienced by student nurses and the underreporting of sharps injuries among healthcare students. He also highlights how research can help universities improve awareness of issues facing students across all healthcare courses and provide more effective support.
  9. Content Article
    This paper aims to explore the insights provided by Safety-I and Safety-II approaches by examining the practical application of two frequently used methods: Systematic Human Error Reduction and Prediction Approach (SHERPA) and Functional Resonance Analysis Method (FRAM). Neither method should be uniquely labelled as a Safety-I or Safety-II approach, however, SHERPA is traditionally used within a Safety-I context, and FRAM is frequently used within a Safety-II context. By examining the application of these two methods to the management of post-surgical deterioration, the authors critically reflect on the analysis logic embedded in each method and their potential contribution to improving patient safety.
  10. Content Article
    In this blog, Louise Roe, an investigator at the Maternity and Newborn Safety Investigations (MNSI) programme, looks at how the questions you ask as a patient safety investigator can affect the quality of the information you receive from staff, as well as having an impact on how they feel about the interview. Louise lays out her journey to obtain higher-quality information from interviews while protecting staff involved in patient safety incidents. She discusses how to ask questions that uncover the 'whys' around decision making at the time of an incident.
  11. Content Article
    Doctors At Work is a series of video podcasts hosted by Dr Mat Daniel. In this episode, Dr Gordon Caldwell shares his experiences of managing and preventing adverse events. He stresses the importance of creating a culture that encourages everyone to speak up. His top tips for preventing errors is to create systems, checklists and routines that ensure a focus on all aspects of care not just the obvious and urgent.
  12. Content Article
    This report is divided into two sections. The first section is contextual and reviews literature, both national and international, that provides insights into the experiences of Black and Ethnic Minority (referred to in this report as BME) and internationally recruited nurse (IRNs). The second section focuses specifically on the literature related to health and social care regulatory bodies within the UK, and the reporting of professionals in relation to fitness to practise.
  13. Content Article
    There is a direct correlation between safety event management practices and care quality outcomes. The right safety management tools, supported by a shared perception and tolerance of risk, will help organisations go beyond reporting event data to improve safety culture.
  14. Content Article
    There is limited guidance on how to effectively promote safety culture in healthcare settings. This systematic review aimed to identify interventions to promote safety culture specifically in oncology settings. The authors concluded that in spite of a growing evidence base describing interventions to promote safety culture in cancer care, definitive recommendations were difficult to make because of heterogeneity in study designs and outcomes. They highlight that implementation of incident learning systems seems to hold most promise.
  15. Content Article
    In the USA, Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions (WHRs) are intended to improve patient safety by reducing resident doctor fatigue. However, compliance with ACGME WHRs is not universal. This study aimed to identify factors that influence resident doctors' decisions to take a post-call day (PCD) off in line with ACGME WHRs. The authors concluded that as most important influencer of residents’ decisions to take a PCD off was related to feedback from their supervisors, compliance with WHRs can be improved by focusing on the residency program’s safety culture.
  16. Content Article
    The Public Interest Disclosure Act 1998 came into force on 2 July 1999. The Act protects workers who disclose information about malpractice at their workplace, or former workplace, provided certain conditions are met. The conditions concern the nature of the information disclosed and the person to whom it is disclosed. If these conditions are met, the Act protects the worker from suffering detriment or dismissal due to having made the disclosure. If the conditions are not met a disclosure may constitute a breach of the worker’s duty of confidence to his employer. This legal framework has received some criticism in recent years for failing to protect some whistleblowers and there have been a number of calls for reform. This research briefing produced by the House of Commons Library, titled Whistleblowing and gagging clauses, includes: Summary Background The duty of confidentiality The legal framework Evolution of the law Proposals for reform of whistleblowing law Whistleblowing in the NHS Gagging clauses Support and advice.  
  17. Content Article
    This website is the home for ‘conversation for kindness’, which is a monthly meeting that was set up in the summer of 2020 by a group of colleagues and friends working in healthcare across Sweden, the UK and the USA. The initial purpose of getting together was to have some time together to continue some initial conversations around kindness, and to explore its role at the ‘business end’ of healthcare.
  18. Content Article
    In this article, sponsored by DHL Supply Chain, the author argues that to tackle challenges and enable a safety-focused culture, a two-pronged approach is needed – introducing safe processes and promoting accountability.
  19. Content Article
    Just Culture got its roots in the airline industry, but according to Dr. Danielle Scheurer, it was tailor-made for health care.
  20. Content Article
    In May 2021, the Irish public health service was the target of a cyber-attack. The response by the health service resulted in the widespread removal of access to ICT systems. While services including radiology, diagnostics, maternity and oncology were prioritised for reinstatement, recovery efforts continued for over four months. This study describes the response of health service staff to the loss of ICT systems and the risk mitigation measures introduced to safely continue health services. It also explores the resilience displayed by frontline staff whose rapid and innovative response ensured continuity of safe patient care.
  21. Content Article
    The harsh reality of surgery often involves grappling with the distressing and emotionally taxing aspects of human suffering that many people outside of healthcare never witness. When complications occur, surgeons feel the weight of their responsibility and are often alone to ruminate with negative thoughts of self-doubt, sometimes leading to anxiety and depression. This article in The American Journal of Surgery examines existing literature on Second Victim Syndrome (SVS) specifically focusing on prevalence among surgeons and factors related to different responses. The authors identify women and junior surgeons at particularly high risk of SVS and peer support as a preferred method of coping but an overall lack of institutional support highlighting the need for ongoing, open conversations about the topic of surgeon well-being.
  22. News Article
    Large numbers of midwives report being left feeling undervalued and afraid to speak up due to bullying and widespread staffing shortages, which some say is putting mothers’ and babies’ lives at risk, according to a new publication shared with HSJ. 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. The report said: “Midwives have described their experiences of toxic cultures within their workplaces, with cliques, preferential treatment, unfounded allegations and poor working conditions leading to a negative impact on their health and wellbeing, including suicide attempts and midwives leaving their job or profession. Read full story Source: HSJ, 13 November 2023 Order a copy of the report
  23. 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.
  24. Content Article
    The 6 Cs are a set of values required by all patient-facing health and social care staff. This includes not only registered healthcare professionals, but also clinical support staff and non-clinical staff who may come into contact with patients or members of the public. 
  25. Content Article
    Healthcare Organisational Culture (OC) is a major contributing factor in serious failings in healthcare delivery. Despite an increased awareness of the impact that OC is having on patient care, there is no universally accepted way to measure culture in practice. This study from Simpson et al. was undertaken to provide a snapshot as to how the NHS is currently measuring culture. Although the study is based in England, the findings have potential to influence the measurement of healthcare OC internationally.
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