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Found 187 results
  1. Content Article
    This study in Surgery aimed to evaluate the association between trauma team function and cardiac arrest in hypotensive trauma patients. Trauma video review was used to collect data from resuscitations of adult hypotensive trauma patients at 19 centres, and 430 patients were included in the study. The results show that better team function is independently associated with a decreased probability of cardiac arrest in trauma patients presenting with hypotension. The authors suggest that trauma team training may improve outcomes in peri-arrest patients.
  2. 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.
  3. Content Article
    Effective teamwork is critical to the provision of safe, effective healthcare. High functioning teams adapt to rapidly changing patient and environmental factors, preventing diagnostic and treatment errors. While the emphasis on teamwork and patient safety is relatively new, significant team-related foundational and implementation research exists in disciplines outside of healthcare. Social scientists, including, organizational psychologists, have expertise in the study of teams, multi-team units, and organizations. This article highlights guiding team science principles from the organisational psychology literature that can be applied to the study of teams in healthcare. The authorsʼ goal is to provide some common language and understanding around teams and teamwork. Additionally, they hope to impart an appreciation for the potential synergy present within clinician-social scientist collaborations.
  4. Content Article
    This is a video presentation from the Royal College of Surgeons in Ireland, looking at facilitation skills for after action reviews (AAR) and the wider process.
  5. Content Article
    The aim of this study in the Journal of Patient Safety was to identify quantitative evidence for the efficacy of interprofessional learning (IPL) to improve patient outcomes. The authors conducted a systematic review and meta-analysis of quantitative patient outcomes after IPL in multidisciplinary healthcare teams reported in the Medline, Scopus, PsycInfo, Embase and CINAHL databases. The authors believe that their results are the first to demonstrate significant quantitative evidence for the efficacy of IPL to translate into changes in clinical practice and improved patient outcomes. They reinforce earlier qualitative work on the value of IPL.
  6. Content Article
    The rise of the #TheatreCapChallenge in 2017, which saw participants donning surgical caps labelled with their names and roles, promises to be a seemingly simple intervention aimed at improving operating theatre communication and patient safety. This narrative review strives to expand upon the perceived and studied benefits of this intervention and address potential concerns that have arisen with the use of these name and role-labelled surgical caps.
  7. Content Article
    Interprofessional communication is of extraordinary importance for patient safety. To improve interprofessional communication, joint training of the different healthcare professions is required in order to achieve the goal of effective teamwork and interprofessional care. The aim of this pilot study from Heier et al. published in BMC Medical Education was to develop and evaluate a joint training concept for nursing trainees and medical students in Germany to improve medication error communication.
  8. Content Article
    Judy Walker looks at the ways in which team learning can contribute to safety in healthcare using tools such as After Action Review (AAR). She explores research highlighted in Amy Edmondson's new book The Right Kind of Wrong that demonstrates the impact on certain safety indicators of flight crews building a team culture through working together consistently. Judy suggests that gaining insights about co-workers through proximity accelerates the process of learning for teams.
  9. Content Article
    This article by NHS England looks at a national project on aligning quality improvement (QI), experience of care and co-production. It explains the principles of co-production and the approach taken to implement the project, as well as highlighting identified themes and key findings. It makes some practical recommendations based on these findings.
  10. Content Article
    David Logan talks about the five kinds of tribes that humans naturally form—in schools, workplaces, even the driver's license office. He argues that by understanding our shared tribal tendencies, we can help lead each other to become better individuals.
  11. Content Article
    This study compared two quality improvement (QI) interventions to improve antenatal magnesium sulphate (MgSO4) uptake in preterm births for the prevention of cerebral palsy. It found that PReCePT improved MgSO4 uptake in all maternity units. Enhanced support did not further improve uptake but may improve teamwork, and more accurately represented the time needed for implementation. Targeted enhanced support, sustainability of improvements and the possible indirect benefits of stronger teamwork associated with enhanced support should be explored further.
  12. 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.
  13. Content Article
    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.
  14. Content Article
    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.
  15. Content Article
    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.
  16. 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’.
  17. 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.
  18. Content Article
    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.
  19. Content Article
    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.
  20. Content Article
    How we treat each other at work has an enormous impact on how teams perform—with potentially fatal consequences if you work in healthcare. Chris Turner, consultant in emergency medicine and founder of Civility Saves Lives, reveals the shocking impact of rudeness in the workplace. He highlights the importance of understanding the complex realities of practice and communication between healthcare professionals in different team environments, if we are to learn from patient safety incidents.
  21. Content Article
    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. 
  22. News Article
    An acute trust has “palpable” cultural problems and staff “at all levels” have described an acceptance of “poor behaviours”, according to the Care Quality Commission. Some staff at Gloucestershire Hospitals Foundation Trust also reported a lack of trust in their senior managers and a “fear of speaking up”. The Care Quality Commission feedback was set out in a post-inspection letter to the trust’s acting chief executive Mark Pietroni last month following an inspection in June. The trust’s CEO Deborah Lee is currently off work as she recovers from a stroke. According to the CQC letter, published in the trust’s board papers ahead of a full inspection report which is due in the autumn, staff “articulated [to inspectors and said they] had observed rudeness and incivility throughout the organisation”. In a written statement, Professor Pietroni told HSJ he “fully recognised” the CQC’s feedback. Read full story (paywalled) Source: HSJ (24 August 2022)
  23. Content Article
    This video shows CCTV footage of Bob being treated for a cardiac arrest on his way to watch a football match at the AMEX stadium in Brighton. The video could be used as a training tool to show how to start cardiopulmonary resuscitation (CPR) and how to use an automated external defibrillator (AED). The video highlights what the AED is analysing and then shocking, showing what happened to the electrical rhythm as it converts ventricular fibrillation (VF) to sinus rhythm. It also features the voice prompts from the cardiac arrest. Bob survived with a completely normal quality of life and was the seventh person (out of seven) at the AMEX stadium to have a cardiac arrest and survive with a normal quality of life. The video shows great team work and human factors interactions between the St John Ambulance volunteers who saved Bob's life, the stewarding team and paramedics.
  24. Content Article
    This article by The Health Foundation looks at an evaluation carried out by Warwick Business School of a partnership between The Virginia Mason Institute and five NHS trusts. The partnership aimed to develop a ‘lean’ culture of continuous improvement which puts patients first by developing a localised version of the Virginia Mason Production System in each of the trusts. The objective was to embed and sustain a culture of continuous improvement capability within each of these five trusts and the NHS more broadly.  Outcomes from the evaluation include insight on progress and achievements in each trust, helping them to further embed a culture of improvement capability. The learning will also enable systems leaders to maximise knowledge on how to support providers to embed and spread a culture of continuous improvement in the NHS.
  25. Content Article
    This guidance on implementing human factors in anaesthesia has been produced by the Difficult Airway Society and the Association of Anaesthetists. Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker wellbeing; implementing human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a ‘hierarchy of controls’ model and classified into design, barriers, mitigations and education and training strategies.
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