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This webinar sponsored by the AHRQ-led National Action Alliance for Patient and Workforce Safety, highlights the importance of safety culture and teamwork in healthcare settings. This webinar, held 15 April 2025, was the third in a three-part series on safety culture in healthcare. Speakers from AHRQ, Duke Center for the Advancement of Well-being Science and Westat discussed how strategies such as conflict resolution and leader engagement are essential for improving healthcare worker well-being and patient outcomes. Panelists answered audience questions on how to get physicians to participate in the patient safety culture surveys and recommended ways to encourage a teamwork climate. Access the recording and presenter materials from this event.- Posted
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Patient safety culture (PSC) is crucial for reducing medical errors and improving patient outcomes globally. This study aims to identify key improvement targets in China’s PSC to promote a safer healthcare environment. It found that while teamwork is a notable strength, there is room to enhance the nonpunitive response to errors. Improving feedback and communication practices can further bolster openness and collaboration within teams, leading to an overall healthier work environment.- Posted
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We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 patient safety tips for surgical trainees. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 priorities for patient safety in surgery Listen to the patient and what matters to them; share decisions with them. Encourage the patient to be in control of their care; they only have to consider their own care and will not be lost to follow up. Trust your instincts; always speak up if you think something is not right. Never be afraid to ask for help if you need it. Look after yourself and your team; there can be no patient safety without team safety. Foster good team working; recognise and respect the value of all team members; take account of everyone’s strengths and weaknesses. Take responsibility for the safety of your patients; patient safety is everyone’s responsibility, not just that of the quality improvement team. Help design systems that make it easier for you to do the right thing. Do not make assumptions. Work as imagined is not the same as work done; make sure you always test any process in practice and confirm that what you think is the case is actually happening. Regularly audit your practice. Celebrate good practice and share your experiences. Take on board feedback and learn from it; be willing to change practice. When outcomes are not as expected, openly discuss and learn, to enable you and your team to reduce the risk of the same thing happening again.- Posted
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Increasingly, healthcare staff are working in teams with many different professionals across different settings, but they may not have been trained to do this. What does research tell us about what makes such teams work well or better? What kind of challenges are presented in shared or integrated care? What is the glue that holds teams together and why is it so important? How can we improve the process of patient referrals from one part of the system to another? What did we learn from pandemic about new ways of working together, within and across services? Host Tara Lamont and guests Jenelle Clarke, Sarah Yardley and Justin Waring share their experience and insights on building relationships across interdisciplinary teams.- Posted
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In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, Peter and Helen speak to consultant endocrinologist Gordon Caldwell, who retired early from the NHS after speaking up about patient safety concerns in his hospital. Gordon shares his experience of raising concerns about unsafe staffing levels while working as a clinical lead and how this led to extreme stress and the decision to retire years before he had planned to. They discuss the importance of transparency, team work and clear record-keeping processes to ensure patients are kept safe and Gordon outlines how lack of accessible patient health records hinders decision-making and can lead to avoidable harm. They also look at how target-led approaches and financial incentives have led to cultural changes in healthcare organisations over the past few decades. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series- Posted
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Over the past three decades, more advanced pre-hospital systems have increasingly integrated doctors into targeted roles, forming interprofessional teams. These teams focus on providing early senior decision-making and advanced interventions while also ensuring rapid transport to hospitals based on individual patient needs. This study aimed to evaluate the benefits of an inter-professional care model compared to a model where care is delivered solely by paramedics. The results suggest that the targeted deployment of interprofessional teams led by doctors in the pre-hospital care of critically ill or injured patients improves patient outcomes.- Posted
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Interprofessional communication and teamwork is critical to patient safety. First-year medical and nursing residents participated in team engagement sessions focused on collaboration and safety behaviours through socialisation, team communication, and engagement skills. Sessions consisted of a pre-recorded scenario of a safety event resulting in a patient's death followed by a facilitated debrief. Escalation of care, SBAR (situation, background, assessment, recommendation), and “ask a question, make a request, voice a concern” were identified as the top 3 safety/communication techniques that could have changed the outcome of the simulated scenario. Approximately two-thirds of participants perceived lack of confidence and fear of giving the wrong information as barriers to safety/communication techniques. -
Content Article
Retained surgical items (RSI) are a never event. This article describes implementation of an evidence-based improvement project to reduce RSI and increase reporting of RSI near misses. An important aim was to improve teamwork and assertive communication between operating room (OR) team members, which was achieved through use of the TeamSTEPPS program. Change in staff attitudes about teamwork was measured using the Teamwork Attitudes Questionnaire, which showed improved perceived teamwork.- Posted
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In this podcast episode, hosts Liz Jones and Darren Kilroy from RLDatix speak to Helen Hughes from Patient Safety Learning about how people, technology, and healthcare come together to create great experiences and support patient safety. The Connection: Where Tech Meets Humanity in Healthcare, is a podcast series from RLDatix, which explores the intersection of technology and human-centred care with the health and care sector. Key talking points from the conversation include: the true scope of patient safety why healthcare leaders must prioritise patient safety how to make patient safety everyone's job essential principles for electronic patient record system implementation.- Posted
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On Friday 27 September 2024, Patient Safety Learning held its first Patient Safety Symposium, organised with the Patient Safety Management Network and Patient Safety Education Network. This blog provides an overview of the event, which focused on the application of Patient Safety Incident Response Framework (PSIRF) tools and methods. Background First introduced in Autumn 2023, PSRIF is the new NHS approach to investigating patient safety incidents. At the core of this is the promotion of systems-based approaches for learning from incidents rather than methods that assume simple, linear identification of a single cause. If implemented effectively, these approaches can help us gain a clearer understanding of the causal factors of harm and lead to safety improvements. However, they also represent a complex innovation in the NHS’s approach to incident investigation, requiring appropriate training and support for those implementing them. How to use systems-based approaches to investigations promoted by PSIRF are regular topics of discussion at two of the biggest peer-support networks hosted by the hub: Patient Safety Management Network (PSMN) – this is an innovative network for patient safety managers and everyone working in patient safety. In just over three years this has grown to now over 1700 members. Patient Safety Education Network (PSEN) – a peer network for those in patient safety education and training roles with over 450 members. These networks provide a shared space to discuss new policies that impact their work, and to share knowledge and resources with their peers. A recurring theme that often emerges from these discussions is an appetite for more practical opportunities to learn about these new systems-based approaches to investigation. Planning the symposium Building on conversations in the Networks, we began planning earlier this year for a new event focused on implementing PSIRF tools and methods. Patient Safety Learning, working with Claire Cox (Chair of the PSMN), Chris Elston (Chair of the PSEN) began planning a symposium that would: Allow members of the Networks from different parts of the country, in different health settings, both inside and outside the NHS, to explore these issues in person. Help to increase understanding and discover the practical application of two of these approaches: Systems Engineering Initiative for Patient Safety (SEIPS) and AcciMaps. Help assess the value of case study based interactive training and the potential for future symposiums. Helping to bring this event to life, the medical technology company BD kindly agreed to host this at their Safety and Innovation Hub in Winnersh, Berkshire. This enabled us to hold the event for free, with members of the PSMN and PSEN invited to attend. Kicking off the day The event was opened with a short set of introductions by: Helen Hughes – Chief Executive of Patient Safety Learning Tracey Herlihey – Deputy Director of Patient Safety (Digital) at NHS England Claire Cox – Chair of the Patient Safety Management Network Tracey Herlihey, previously Head of Patient Safety Incident Response Policy at NHS England when PSIRF was introduced, reflected on how the framework had evolved over the past couple of years. She noted positive signs that PSIRF’s introduction had enabled people in different roles to start to talk more openly about patient safety incidents. This is particularly important as different roles can bring different perspectives on how to use PSIRF tools, allowing us to learn from each other. She also emphasised the real power and value of events such as this symposium, where people can be brought together to discuss how best to make PSIRF work for patient safety improvement. Before going into the day, all attendees were asked to follow a simple set of rules, based on how the PSMN and PSEN operate: Speak in plain English, no acronyms. Introduce yourself by your name and your place of work – no job titles, a flattened hierarchy where all voices are valued. Provide a safe space to ask questions/peer support. Feel free to network, make connections and steal ideas. These introductions were followed by a short icebreaking activity, before attendees headed into their first workshop of the day. Workshop 1: AcciMaps The first workshop began with a session on the history and principles of AcciMaps from Professor Mark Sujan. Mark is a Chartered Ergonomist and Human Factors specialist and has worked in patient safety and other safety critical industries for over 25 years. He is also Senior Science Investigation Educator at the Health Services Safety Investigations Body. Accimaps, or Accident Mapping, is a tool initially developed by Jens Rasmussen. Applied in patient safety, it involves creating a graphical presentation of factors within a system that contribute to the occurrence of a patient safety incident. These factors are arranged into a series of levels representing different parts of the system that the event took place in: Government policy and budgeting. Regulatory bodies and associations. Local area government planning and budgeting. Company planning. Physical processes and actor activities. Equipment and surroundings. Mark’s key reflection that resonated with many symposium participants was of the value of a different mindset in incident investigation, not just about the application of the tools such as Accimaps. Following Mark’s insightful and informative presentation, attendees were split into groups at tables and provided with a scenario of a patient safety incident that needed to be investigated. Though fictional, this was drawn from aspects of previous real-life cases. Each table was asked to consider the issues and produced their own AcciMap. Reflecting on this exercise, some key thoughts from attendees included: This approach could help to gain a viewpoint of the ‘bigger picture’ in which an incident occurs; it’s most definitely a reflection of the system in which an incident occurs and not just looking at the ‘people factors.’ There were some significant differences in the causal factors identified by different groups, reflecting the mix of expertise and roles in the room. This reinforced the value of a team-based approach to applying Accimaps and the value of educational events, working through simulations to inform learning and application. The value of using debriefing techniques in healthcare alongside this, and building this into the wider organisational culture—not just when incidents occur. Also taking an appreciative inquiry approach, looking for what went well within the scenario. Other systems-based approaches that could work alongside this, such as After Action Reviews and Swarm Huddles. Lunch break and escape room During the lunch break, attendees had the opportunity to participate in two patient safety ‘escape rooms’ in the BD Safety and Innovation Centre simulation suite, set up as a hazard identification exercise. Participants assessed the hazards in a community based setting and another in a hospital environment. This was a fun approach to a serious set of issues that generated much discussion. There was also an opportunity for patients to purchase a copy of a new book, Patient Safety: Emerging Applications of Safety Science, from Class Professional Publishing. This book brings together contributors from a variety of academic and healthcare professions, alongside those with lived experience, to help understand some of the emerging theories of safety science and their practical application. It is written by people who work in patient safety, including members of the PSMN and PSEN who were in attendance at the symposium. Workshop 2: SEIPS The afternoon workshop kicked off with an introduction to SEIPS by Nikki Fountain, Network member and Business Manager to the Chief Medical Officer at Great Ormond Street Hospital for Children NHS Foundation Trust. The symposium attendees were asked to carry out a SEIPS analysis after being shown a short video that illustrated a simulation of a routine and normal work scenario—taking blood in an ill-suited work environment. SEIPS is a framework for understanding outcomes within complex socio-technical systems. It is a conceptual tool that depicts the interactions between three key components: work system, process and outcomes. Patient safety incidents result from multiple interactions between work system factors. SEIPS prompts you to look for interactions rather than simple linear cause and effect relationships. Following Nikki’s introduction, attendees were split into groups at tables again and asked to carry out a SEIPS analysis of the scenario they had watched. Chris, Claire and Helen enjoyed creating the video although no acting awards are likely to be awarded! Reflecting on this exercise, some key thoughts from attendees included: While there were elements of good teamwork in the scenario, there was a notable trend of staff not recognising other colleagues becoming gradually overwhelmed. While nothing went ‘wrong’ in this scenario, the patient received the treatment required, observation showed that both the patient and staff member had a negative experience and there were potential risks in handling and supply of samples that could lead to problems. There were areas where there may be obvious quick fixes to put in place, but the challenge would be to make these sustainable under normal work pressures. There was a conversation about how patients could be involved in SEIPS style analysis, and how this would work in practice. Some reflections of SEIPS being used individually at trusts, when this is perhaps more effective as a group tool. End of day reflections Concluding the day, attendees reconvened in the main meeting space and shared reflections on the event, which included the following points: Great to have such a diverse range of participants at this event. One table featured student nurses, a representative from NHS England, a GP and a senior director from an independent trust. This was a genuine and much valued flattened hierarchy that enabled confident engagement and shared learning. You don’t need to wait for a safety incident to use these tools for safety improvement. Everyone can make a valuable contribution to patient safety discussions, both those in clinical and non-clinical roles. Different types of expertise are greater than the sum of the parts when pooled together. Appetite to see more system leaders/decision makers in the room for these type of events to underline the commitment to transforming how we approach incident investigation in trusts. Following the event we asked attendees to complete a short feedback form offering their reflections on the day. When asked what was their key takeaway learning, answers included: “The timeliness of utilisation of various tools, and the need to be aware of perceptions affecting the outputs from using the tools and the need for a multi-disciplinary approach.” “Mindset over method. Diversifying thinking. Accimapping for improvement rather than for incidents.” “Networking empowers. Great to hear that other organisations are struggling with similar issues, that proves that we are on a journey to change the safety culture.” “We're all in the same boat, it was great to hear how other organisations are embedding some of the learning tools.” “Thinking about the different tools being part of your learning response toolkit and that it's not either/or...you may want to use more than one tool and the same incident - different ways of looking at what happens and there is no one way or right way.” We also asked attendees if there were any PSIRF tools or approaches they would be more likely to implement at their organisation after attending this event. Responses included both Accimaps and SEIPs, the subject of both workshops, but also SWARM huddles which were discussed at several points across the day. Other general reflections from attendees included: “Really useful to have a space and down time for reflection, thinking and learning with and from peers. Great that the schedule was generous with time and only had 2 sessions and lengthy breaks to enable this.” “It was truly wonderful, so well thought out so engaging. Attending on my own and having table already mapped out was brilliant. The interaction. The lunchtime escape rooms and the ice breaker. Such a great networking opportunity. The best meeting in this field ever.” “Love the honesty in the room and sharing.” “It was an excellent networking opportunity, and I have since been in contact with a new peer. We have shared our current PSII reports and provided a critical friend approach to each other.” “A wonderful opportunity to network and learn from each other, really well considered agenda, and fabulous presenting. Felt like a family as we know each other virtually. The informal 'ness' of the setting allowed us to really network and get to discuss key issues we face. I really enjoyed listening and learning from the experts.” How to join a hub network You can join by signing up to the hub today. When putting in your details, please tick the relevant Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. The founders of each group have set the following criteria for who can join: Patient Safety Management Network – UK hub members in a health or care service provider organisation who have an active patient safety role. National NatSSIP Network – UK hub members involved in or leading NatSSIP/LocSSIP work in their organisation. Patient Safety Partner Network – UK hub members in a health or care service provider organisation who volunteer officially as a Patient Safety Partner. Patient Safety Education Network – UK hub members involved in patient safety education/ training in their organisations. The community excludes commercial training providers. Patient Safety Paediatric Leaders Network – UK hub members who are strategic-level decision makers in a specialist children’s hospital or unit with a leadership responsibility for patient safety and/or quality. You should have a role that reports to a member of the Executive and have been nominated by your CMO or CNO, and are committed to reducing avoidable harm and improving the quality and safety of paediatric care.- Posted
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All leaders and teams will experience failure at some point – the key is to fail well. In this presentation, Harvard Business School professor Amy Edmondson identifies three types of failure. She explains why some failures aren’t necessarily bad, showing how to turn a failure into a success that will change outlooks and energise teams and teamwork.- Posted
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The Care Quality Commission’s (CQC) recent national review of maternity services describes how toxic interprofessional cultures are impacting on quality of care. Multiple inquiries have found that poor multidisciplinary teamwork during childbirth causes delays in emergency intervention, as well as birth trauma, with recommended change slow to come. Lord Darzi’s recent report on the wider NHS, which describes the “succession of scandals and subsequent inquiries into maternal care”, suggested that deeper conversations may need to be had on issues such as culture in maternity services. This blog describes some of the professional culture dynamics in maternity services, why it matters when they clash, and suggests how focusing on our shared values can help us move towards resolution. We should not shy away from a problem because it is difficult to solve.- Posted
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In this blog, Patient Safety Learning's Content and Engagement Manager, Stephanie O'Donohue highlights some of the common barriers to collaborating for safety. She argues that we need time and space to listen and build trust between different groups if we are to really harness the power of collective insight and make safety improvements. When I joined Patient Safety Learning in 2019 I was shocked to discover there are 11,000 preventable deaths each year in the UK due to unsafe care. And deaths of course are not the only measure of harm. Unsafe care can also leave patients with chronic pain, psychological trauma, permanent damage and life-limiting repercussions. My role includes proactively seeking opportunities to engage, collaborate, listen and create content that will help to influence positive change around key safety issues. I work with patients, researchers, clinicians, charities, healthcare leaders and families who have an interest in patient safety and reducing harm in healthcare. It is always a privilege speaking to such a range of people driven by a desire to improve outcomes. Comms people like me often focus on making sure their content connects with key stakeholders, but my work has increasingly become about connecting stakeholders with one another. I mean this in both the traditional sense of introductions and also in the way I facilitate and create content. Because when it comes to those involved in patient safety, it has become clear to me that you are destined to fail if you don’t collaborate. If key voices are missing from around the table, your solutions will never be as whole or effective as they could be. So why doesn’t it happen more? Why don’t patients, frontline staff, decision makers and researchers just work together to approach safety issues with combined wisdom and insight? 5 common barriers to collaborative working in patient safety Defensiveness When patients, relatives and campaigning organisations seek answers and to share their experiences and insights around safety, they are too often met by a wall of defensiveness. Most of the time, these people are reaching out trying to help the system prevent harm from occurring. They are offering their time and input; it should be welcomed. If the response to this is to dismiss, deny or shut them out, their desire to work with the system can be replaced by a new sense of anger, frustration and injustice. Anger If people are consistently shut out of key and central conversations around patient safety of course they will become distrusting of the system, of course they will want to advocate loudly given any opportunity, of course they will want to call out the treatment they have had. This can influence the ferocity with which people engage with leaders and clinicians via public channels like podcasts, online conferences and social media. Unfortunately, this can reinforce a fear of inviting people in, even among those clinicians who want to hear from patients and be informed by lived experience. Lack of time Even when patients, clinicians and others do manage to come together, time often constrains the effectiveness of conversation. There is little opportunity to provide background, introduce individuals fully, understand their experiences and motivations, and establish shared aims. Lack of time to communicate and connect at the start of a collaboration can create very rocky foundations for what should essentially become a ‘team’. Fear We know from the NHS survey that many staff still do not feel safe to speak up when they have concerns. While other industries actively promote and welcome individual insights and wider conversations around risk and system safety, healthcare lags behind with individuals fearful to talk openly about avoidable harm or to share learning when things have gone wrong. Leaders need to walk the walk when it comes to sharing failures with candour, taking action to prevent future harm and developing a culture where staff feel safe raising concerns that, if acted on, could be life-saving. Strong and respectful lines of communication between the frontline and leaders have to exist to make sure no one is frightened to speak up for safety, and valuable insights do not get ignored. Leaders should also be consistently modelling and evidencing the value of patient engagement for safety, so that frontline staff feel inspired and safe to follow their lead. Absence of proactive engagement At Patient Safety Learning we do a lot of proactive engagement work. Because we understand the value of the insights and knowledge that exist outside of our team. And honestly, it’s not difficult. People respond really well to being approached in this way – often commenting on how refreshing it is to be invited in and to be heard. It shouldn’t be refreshing though, reaching out to those who have expertise outside of your organisation should be a given. The healthcare system should be investing time in actively seeking out and contacting researchers, patients and campaigners who can help them understand the bigger picture when it comes to patient safety issues. And not just when harm or inequality has been highlighted. It needs to be interwoven as a preventative measure, a way to manage risk. 4 ways to support collaboration in patient safety Make space for each other We all know resources are stretched but collaborating for patient safety takes time. Making time to listen to a patient’s experience is important. You may need to listen several times because that is part of making space for people at the table and being reminded that the human impact should be core to any safety project. Listening will help you understand motivation and any anger present, and respond with compassion and hopefully a desire to make a difference. Listening to the clinical perspective is equally important, we need to allow time to ask questions, translate medical terminology into plain English and for clinicians to explain the challenges they face in delivering safe care. Keep an open mind Constantly being dismissed by the healthcare system as a patient or campaigner can take its toll on your trust of individuals. But to move forward, an open mind is needed because there are people who will share your aims, motivations and are equally driven to help. Just as the system needs to let people in, those who have been harmed by unacceptable past interactions need to be open to those who genuinely want to collaborate moving forward. Not always easy to rebuild that faith but it opens up more opportunity for progress. Be curious Asking questions is one of the most powerful communication tools. It shows respect, interest and a desire to learn from others - three key components of good collaboration. If you want to know what the barriers are to someone implementing change – ask. If you want to know how an experience made someone feel – ask. If you want to know what each person in the room wants to achieve – ask. If you want to know how you can help – ask. If you’re not asking anyone any questions – ask yourself why! Invite people Use your channels to start conversations and ask people to share their insights at the beginning of any project. You will never have all the answers (and be wary if you think you do), reaching out to others will give you more of a chance of finding them. My reflections come from a communication perspective and from witnessing the power of collaboration when people come together for safety. We need everyone to speak up for safety but, more importantly perhaps, we need to acknowledge the time and space that is needed to really listen to each other.- Posted
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This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services. The investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. In its formal report, published on the 19 October 2022, it stated that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed. At the beginning of its response to the Investigation and its recommendations, the Government states that at a national level, the Minister for Mental Health and Women’s Health Strategy will chair a newly created maternity and neonatal care national oversight group. This will bring together the key people from the NHS and other organisations, including the CQC and HSIB, to look across maternity and neonatal improvement programmes and the implementation of recommendations from this and other maternity reviews, to ensure a joined-up and effective approach. Summary of the Government response to each of the recommendations Recommendation – The prompt establishment of a Task Force with appropriate membership to drive the introduction of valid maternity and neonatal outcome measures capable of differentiating signals among noise to display significant trends and outliers, for mandatory national use. NHS England (NHSE) has established a Reading the Signals Data Co-ordination Group, referred to in this report as the co-ordination group, who will bring together a series of data projects which aim to make sure the right data will be used in the right way to identify and support trusts who may be vulnerable to bad outcomes. NHSE have also formed a Maternity and Neonatal Outcomes Group, acting as a task force in response to the recommendation in the East Kent report. Chaired by Dr Edile Murdoch, this group has met and is progressing work towards the identification of outcome measures that will, as this recommendation states, differentiate signals among noise to display significant trends and outliers. Recommendation – Those responsible for undergraduate, postgraduate and continuing clinical education be commissioned to report on how compassionate care can best be embedded into practice and sustained through lifelong learning. Department of Health and Social Care (DHSC) will lead the response to this recommendation in a central coordination role involving relevant national partners, closely supported by NHSE. It will coordinate activity to: Map how compassionate care is currently being taught at all levels and across professions, whether this be formally or as part of in practice training. Share good practice and examples of how barriers have been overcome with all those responsible for training, from higher education institutions to those providing preceptorship and clinical supervision at trust level, on the embedding of compassionate care. Identify where gaps depend on national level change or coordination and work with relevant bodies or other government departments to consider how these could be addressed. This will also consider how the government, NHSE and other arm’s length bodies can influence and support sustainable system level change. Recommendation – Relevant bodies, including Royal Colleges, professional regulators and employers, be commissioned to report on how the oversight and direction of clinicians can be improved, with nationally agreed standards of professional behaviour and appropriate sanctions for non-compliance. DHSC will lead the response to this recommendation, in a central coordination role looking across the whole system. This work will be supported closely by NHSE. It will coordinate activity to: Map current responsibilities around oversight and direction. Share good practice and learning on proposed solutions to address gaps in roles and responsibilities in oversight and direction, and support for managing concerns about practice. Identify where gaps in oversight depend on national level change or coordination and work with relevant bodies or other government departments to consider addressing these. This will include examination of where regulators could contribute to identification of poorly performing trusts. Recommendation – Relevant bodies, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and the Royal College of Paediatrics and Child Health, be charged with reporting on how teamworking in maternity and neonatal care can be improved, with particular reference to establishing common purpose, objectives and training from the outset. DHSC will lead the response to this recommendation in a central coordination role, with the close support of NHSE. It will coordinating reports that will: Provide evidence through experience and examine existing research on how and where teamwork is being done well. Bring together examples of good practice to support trusts and all those supporting teamwork to utilise as a resource of solutions to barriers and identified gaps. Consider whether, where gaps and barriers are identified, relevant bodies or government can support solutions. Recommendation – Relevant bodies, including Health Education England, Royal Colleges and employers, be commissioned to report on the employment and training of junior doctors to improve support, teamworking and development. DHSC will lead the response to this recommendation and be supported closely by NHSE. It will coordinate reports that will: Map how the support for junior doctors, and those who have yet to complete training including locums, is translated into practice, what access they have to development and how teamwork is embedded within this. Identify and share good practice and learning around proposed solutions to address gaps in roles and responsibilities for supervision for specific groups. Consider whether the government and its arm’s length bodies (ALBs) need to provide support to the system to address gaps and barriers. Recommendation –The Government reconsider bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies. Recommendation – Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards. Recommendation – NHSE reconsider its approach to poorly performing trusts, with particular reference to leadership. The Government has provided one response to the above three recommendations which includes the following points: The government acknowledges the failure to adhere to this duty of candour that was so evident in this report and recognises the need for action in this area in order to make sure the duty is effectively applied and to create a culture of candour throughout organisations. When considering the broader recommendation made by Dr Kirkup for a bill to place a “duty on public bodies not to deny, deflect and conceal information from families and other bodies”, the government will set out its position in response to Bishop James Jones’ 2017 report on the experiences of the families bereaved by the Hillsborough disaster in due course. To help monitor when reputation management is superseding transparency of trust boards, the CQC, as part of its new inspections approach, will continue to consider trust leadership at executive team and trust board level as part of its key lines of enquiry, using the well led framework. In the 2023 to 2024 financial year, NHSE is commissioning a support programme for board safety champions to focus on developing the leadership, culture and processes needed for them and their teams to be able to use qualitative and quantitative data to improve maternity and neonatal safety in their organisations. Recommendation – The Trust accept the reality of these findings; acknowledge in full the unnecessary harm that has been caused; and embark on a restorative process addressing the problems identified, in partnership with families, publicly and with external input. In their response the Government note the actions that the Trust has taken following the publication of the report on the 19 October 2022, including that specific improvements in maternity and neonatology services will be overseen by a maternity and neonatal assurance group, reporting to the Trust’s board. Related reading 'Reading the signals': Maternity and neonatal services in East Kent – the Report of the Independent Investigation (19 October 2022) Prevention of Future Deaths Report: Harry Richford (3 February 2020) Patient Safety Learning: Will lessons be learned? An analysis of the systemic failures in the East Kent Maternity report (17 November 2022)- Posted
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AHRQ: Team STEPPS
Patient Safety Learning posted an article in How to engage for patient safety
AHRQ's TeamSTEPPS - Team Strategies and Tools to Enhance Performance and Patient Safety - is an evidence-based set of teamwork tools, aimed at optimising patient outcomes by improving communication and teamwork skills among healthcare teams, including patients and family caregivers.- Posted
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This report by Healthcare Inspectorate Wales (HIW) relates to vascular services provided by Betsi Cadwaladr University Health Board following the de-escalation of these services as a Service Requiring Significant Improvement (SRSI). The review outlines that while progress has been made against all nine recommendations made by the Royal College of Surgeons, the health board still has improvements to make. Review recommendations The health board must consider its responsibilities in line with the NHS Wales Putting Things Right process. This is to establish whether timelier responses could have been given following the two formal complaints it received, and whether it is assured that updates were given appropriately throughout the course of the complaint investigation. The health board should set out what action will be taken to ensure that in future, people are communicated with in a timely manner when raising concerns. The health board must maintain the record keeping audit process, to assure itself that the standards expected for record keeping, are consistent and are being maintained in the immediate and long term. Particularly within its vascular services, but also across the health board. This includes record keeping for all members of the MDT. The health board must explore the reasons for reported inconsistencies in the implementation of the Diabetic Foot Pathway across its three acute sites. The health board must consider and address the issues reported to us regarding the lack of clinical areas at YG, to review patients pre and post operatively. The health board must consider the comments and findings in this report regarding staff culture and the perceptions of different teams. This is to establish whether there is learning, or development required to improve the working relationships across all teams, to support a positive working culture. The health board must consider the comments made by staff regarding the ongoing issues following the implementation of new pathways. This is to establish whether the pathways need to be revised, or further action is required for compliance with the pathways as appropriately. The health board must ensure that all staff are completing all aspects of the consent process as applicable and are documenting this within the relevant clinical records. In addition, further consent process audits must be undertaken and continue on a regular basis, with feedback provided to all staff and actions implemented as applicable. The health board must ensure that: a) All clinical record entries are filed in chronological order; b) Surgical operation records are filled promptly after the surgical procedure. The health board must address the issue where we found examples of misfiling an incorrect patient clinical record, in a different person’s record. The health board must ensure that clinical documentation entries are signed with the clinician’s name legibly printed for identification of the author. The health board must ensure a process is in place to evaluate the sustainability of its vascular service support from UHNM to determine what arrangements will be in place once current agreements end in 2024.- Posted
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- Surgery - Vascular
- Wales
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Content Article
he NHS needs every one of its 1.4 million staff, but nobody is perfect every day of their career. Human factors have a huge impact on staff and patients. After witnessing poor behaviour in the workplace, co-workers are less effective and patients have worse outcomes. An unpleasant working culture also reduces camaraderie in teams and can lead to resignations. This is a vicious cycle of overwork and burnout that the NHS can’t afford. We need to nurture our workforce. In this BMJ opinion article, Scarlett McNally suggests focusing on three areas: expecting a minimum standard of behaviour at all times rather than perfectionism; identifying when intense focus is needed; and building effective teams. The minimum standard should be an expectation of “respect” at all times.- Posted
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- Human factors
- Organisational culture
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Content Article
Leadership walkarounds (LWs) have been promoted in practice as means to drive operational, cultural and safety outcomes. This systematic review in BMJ Open Quality aimed to evaluate the impact of LWs on these outcomes in the US healthcare industry. The authors found only positive association of LWs with operational and perception of cultural outcomes.- Posted
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- Leadership
- Teamwork
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Content Article
RCGP: Physician Associates update (October 2023)
Patient-Safety-Learning posted an article in GP and primary care
Physician associates (PAs) support doctors in the diagnosis and management of patient. They are often employed in general practice as members of the multidisciplinary team, trained in the medical model. This update outlines the Royal College of General Practitioners' (RCGP's) policy position on PAs. The RCGP sees PAs as having an enabling role to play for general practice, but highlights that they must always work under the supervision of GPs and must be considered additional members of the team, rather than a substitute for GPs.- Posted
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- GP
- Physician associate
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Authors of this study, aim to describe the development of a post-simulation reflective learning conversations model in which a number of contributing factors to achieve clinical reasoning optimization were addressed.- Posted
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- Training
- Simulation
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Productivity is misunderstood at every level in the NHS, not least because the leadership so often use the word to mean something entirely different. So what is it and what are the big misunderstandings about it? In his LinkedIn post, Stephen Black discusses what productivity is and what misunderstandings are feeding the problem.- Posted
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- Organisation / service factors
- Leadership
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Content Article
Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), spoke to us about a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’.- Posted
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- PSIRF
- Anaesthesia
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Content Article
Monitoring and responding to deterioration in social care settings is critical to providing safe, effective and responsive care. Front-line staff are pivotal for highlighting change to wider teams and managing low to medium risk individuals in their place of residence. However, there is a core set of principles that most systems use which may not be used by non-clinical staff in residential settings. This case study explores an intervention to empower non-clinical staff to take observations. The Whzan blue box contains a digital tablet and equipment to take temperature, pulse, oxygen saturation levels and blood pressure measurements. Staff were trained and supported on site to use the system and set up a digital platform to share measurements with wider teams. Staff fed back that they felt empowered and able to better engage in conversation with health care professionals, highlighting the importance of having a common language. This case study was submitted to the Care Quality Commission (CQC) by North East and North Cumbria ICB.- Posted
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- Social care
- Staff support
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Workplace-based knowledge exchange programmes (WKEPs), such as job shadowing or secondments, offer potential for health and care providers, academics, and policy-makers to foster partnerships, develop local solutions and overcome key differences in practices. Yet opportunities for exchange can be hard to find and are poorly reported in the literature. This study, published in BMJ Leader, aimed to understand the views of providers, academics and policy-makers regarding WKEPs, in particular, their motivations to participate in such exchanges and the perceived barriers and facilitators to participation. Results showed WKEPs were reported to be valuable experiences but required significant organisational buy-in and cooperation to arrange and sustain. To benefit emerging partnerships, such as the new integrated care systems in England, more outcomes evaluations of existing WKEPs are needed, and research focused on overcoming barriers to participation, such as time and costs.- Posted
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- Teamwork
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How to influence without authority
Patient_Safety_Learning posted an article in Leadership for patient safety
This article by Jesse Lyn Stoner, argues that leading without relying on authority is a higher evolutionary skill. It supports developing adult relationships based on mutual objectives and creates work environments grounded in respect for human dignity. Stoner outlines “The 8 Portals of Influence” – Ways to Influence Without Authority. Character – Your own character is your greatest source of influence. Do you lead by example and follow through on your commitments? Are you respectful, authentic and trustworthy? People will believe you are motivated by the common good and not personal gain. Expertise – Do you have content knowledge and experience? Are you a thought leader? Do you understand the process needed to accomplish the objective? You can influence by providing a clear logic, an explanation of the benefit, and reassurance that it is the right course of action. Information – Do you have access to valuable information? You can influence by providing data and proof. Connectedness – Do you form close relationships with people? Do they enjoy working with you? Do you engender loyalty? You can influence by appealing to shared values and your emotional connection. Social intelligence – Do you offer insight into interpersonal issues that interfere with work and help facilitate resolution of issues? People trust that you’ll be able to help them work together effectively. Network – Do you put the right people in touch with each other? Can you garner the endorsements of credible people? People will trust that you will get the support needed. Collaboration – Do you seek win-win solutions, unify coalitions and build community? People will trust that you can help them become a high performing team that accomplishes its objectives. Funding – Do you have access to financial support? If financial resources are required, it’s easier to influence when you can ensure adequate funding is available. The below infographic has also been developed in relation to Stoners work. The below image was created by Tanmay Vora. Read the full article by Jesse Lyn Stoner, published by the Seapoint Center for Collaborative Leadership, via the link below.- Posted
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- Leadership
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