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Content ArticlePatient Safety Tool Box Talks© Theme 1 talks - Person centred care and supportre and Support Patient Safety Tool Box Talks© Theme 2 talks - Effective care and support Patient Safety Tool Box Talks© Theme 3 talks - Safe care and support Patient Safety Tool Box Talks© Theme 5 talks - Leadership, governance and management Patient Safety Tool Box Talks© Theme 8 talks - Use of information
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Content ArticleWhilst the principle aim of the guide is to support Guardians’ training needs, reflective practice and self-development, it could also be useful for: Regional and National Networks who might like to use the resources to support a local conversation about aspects of good practice Induction and other training programmes, for which the guide provides easily accessible materials to use and download. Organisations keen to support their Guardians by understanding the nature and complexity of the role. Informing Guardian’s organisational appraisals and PDPs. The Guide offers a short perspective on each of twenty-one competencies alongside questions for reflection and links to supportive material which will be regularly refreshed.
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Community PostThis year's theme for World Patient Safety Day (17 September) is Health Worker Safety: A Priority for Patient Safety. We know that staff safety is intrinsically linked to patient safety but we need your insight to help us understand what matters most when it comes to feeling safe at work. So we're asking you to tell us: What is most needed for health and care staff to feel physically or mentally safe at work? In this short video, Claire Cox (Patient Safety Learning's Associate Director of Patient Safety and a Nurse) shares her top three. What do you think is most needed? Please join the conversation and help us speak up for health worker safety! Nb: You'll need to sign in to the hub to comment (click on the icon in the top right of your screen). If you're not a member yet, you can sign up here for free.
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Introduction to Human Factors & Performance Science - Distance Learning
Patient Safety Learning posted a calendar event in Community Calendar
untilThis unique 1-day distance-learning course from Medled is delivered via Zoom by our expert trainers in a format designed to maximise learning retention and application of knowledge. You'll learn to: Understand the concept of systems thinking and models of safety – looking beyond the individual and the flawed concept of ‘Human Error’. Gain an introduction to human capabilities & limitations & how those influence quality and safety of care – how humans can be heroes and hazards. Be able to unpick the nature of human fallibility and why practice does not always make perfect. Have the knowledge to proactively contribute to the safety culture in your organisation. Be able to recognise error-provoking conditions and influence your systems of work. Understand the relationship between stress and performance/risk of error. Take away a tangible model for understanding the relationship between our physiological needs and performance – do we set ourselves up to fail? Understand strategies to optimise high-performance teamworking with ad hoc teams. Evidence-based, utilising cutting edge safety & performance science this course is suitable for all Healthcare Professionals, both clinical and non-clinical; it is applicable to all departments and multi-disciplinary teams. Accredited by Chartered Institute of Ergonomics & Human Factors, you'll take part in interactive actitvities and leave with practical tools to take away. Registration -
Content ArticleAllow me to start this essay with a real personal story: more than a decade ago, while I was doing my Transplant & Hepato-Biliary Surgery fellowship in the USA, I had to have elective orthopaedic surgery. The good news was the hospital where I was about to have the surgery was the number one in the US News Ranking for Orthopedics that year. The bad news was that I was literally ‘terrified’ while I was in the pre-op holding area, just before I was wheeled into the operating room! How could that be? Me: the surgeon, terrified of having a straightforward orthopaedic procedure in the number one orthopaedic surgery hospital in the US? The answer was yes. It was precisely for this reason – that I am a surgeon who knew what could go wrong in a clinical unit like the OR and that I was terrified of becoming just another casualty of a medical error! Back in 2016, in their book 'Safer Healthcare', Charles Vincent and Rene Amalberti beautifully articulated the safety levels in hospitals where they classified five levels of care: Level 1: The care envisaged by standards. Level 2: Compliance with standards / ordinary care with imperfections. Level 3: Unreliable care / poor quality, but the patient escapes harm. Level 4: Poor care with probable minor harm but overall benefits. Level 5: Care where harm undermines any benefit obtained. As a practicing healthcare professional (a surgeon), I can, unfortunately, say that the majority of clinical units in hospitals are performing around Level 3 (unreliable care / poor quality, but the patient escapes harm) with fluctuations towards Level 4 (poor care with probable minor harm but overall benefits) for below-average performers or Level 2 (compliance with standards / ordinary care with imperfections) for a very few leading medical centres... sometimes! Patient safety was defined as the absence of harm. I believe it is time to define patient safety using a patient-centric approach where patient safety can be defined as the absence of harm for each patient, by the right person(s), at the right time(s) and the right place(s). Such definition would help us think about a systemic and individual framework to safety, where safety is customised to every patient, all the time, in the backdrop of a safe clinical unit. Last year marked the 20th anniversary of the landmark paper 'To Err is Human'. Although the past 20 years have seen much progress in the understanding of the healthcare safety which helped bridge the knowledge gap in this significant field, we still have a significant implementation and structural gap, which continues to contribute to the ongoing inherently weak safety conditions for patients. The main reason for writing this essay is to say that 20 years after To Err is Human, the majority of hospitals are treading around Level 3 (mediocre patient safety conditions to use layman’s terms!). Such a situation is entirely unacceptable for high-reliability industries like aviation, nuclear, and oil and gas. Fifty to sixty years ago, these industries were not as safe as they are today but reached their watershed moments (tipping point) and had to transform their safety practices. This essay is a call for action to highlight the following: Healthcare continues to be structurally weak when it comes to the safety conditions. This lack of resilience leads to ongoing medical errors and harm to patients. There is an urgent need for us to have a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. As healthcare systems are complex adaptive systems, the only way to do that is to build resilience in the system. Here are my practical solutions: Adopting co-production principles: co-design, co-delivery and co-assessment. Introducing complementary checklists for both patients and healthcare professionals throughout the patient journey. Safety reconciliation: transition of care or any patient transfer carries potential patient harm – e.g., fall, tubes or IV dislodgement, communication failure with new staff members, such as radiology department technicians, etc. Hence, it is vital that a safety reconciliation is performed by both the patient/families and healthcare professionals (co-production) using checklists. Leveraging implementation science: by introducing safety principles into the day to day clinical practices at the bedside (undergraduate, postgraduate, and board-certified practitioners). Human Factors Engineering (HFE): introducing HFE principles into bedside clinical practice – e.g., effective communication, situational awareness, flat hierarchy and team-based simulated learning – will introduce resilience into the system and help reduce potential harm to patients.
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News Article
The medical school trying to become anti-racist
Patient Safety Learning posted a news article in News
A major British medical school is leading the drive to eliminate what it calls "inherent racism" in the way doctors are trained in the UK. The University of Bristol Medical School says urgent action is needed to examine why teaching predominantly focuses on how illnesses affect white people above all other sections of the population. It comes after students pushed for reform, saying gaps in their training left them ill-prepared to treat ethnic minority patients – potentially compromising patient safety. Hundreds of other UK medical students have signed petitions demanding teaching that better reflects the diversity of the country. The Medical School Council (led by the heads of UK medical schools) and the regulator, the General Medical Council, say they are putting plans in place to improve the situation. A number of diseases manifest differently depending on skin tone, but too little attention is given to this in training, according to Dr Joseph Hartland, who is helping to lead changes at the University of Bristol Medical School. "Historically medical education was designed and written by white middle-class men, and so there is an inherent racism in medicine that means it exists to serve white patients above all others," he said . "When patients are short of breath, for example, students are often taught to look out for a constellation of signs – including a blue tinge to the lips or fingertips – to help judge how severely ill someone is, but these signs can look different on darker skin." "Essentially we are teaching students how to recognise a life-or-death clinical sign largely in white people, and not acknowledging these differences may be dangerous," said Dr Hartland. Read full story Source: BBC News, 17 August 2020 -
EventuntilThis is a global online event from the Royal College of Surgeons of Edinburgh, relevant to all who work in healthcare, with a focus on the role of the surgical team in delivering care. Everyone is invited to register for this free online event. The participants will be encouraged to use a smartphone or another second screen to actively participate and answer questions. This event will be delivered on Zoom – questions can be submitted, and the use of the chat room is encouraged. Registered participants will get a copy of the webinar recording, slides, questions and answers, chat room, Menti results and a Spotify playlist. The conference panel is formed of a diverse group of experts with a range of skills in healthcare, surgery, education, business, leadership, coaching, training, human factors, and situational awareness. They have experience working with high performance teams, global industries, firefighters, aircrews, and fighter pilots in theatres of operation, cockpits, and on oil rigs. All have worked in high performance teams and understand the critical importance of listening and communication. The conference is headlined by the global leader, Bob Chapman, CEO of Barry-Wehmiller and co-author of the bestselling book; ‘Everybody Matters – the extraordinary power of caring for your people like family’. Further information and registration
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Airway safety webinar
Patient Safety Learning posted a calendar event in Community Calendar
The Patient Safety Movement Foundation is proud to partner with MedStar Health to offer free Continuing Education (CE) credit for this patient safety webinar. With Dr. Arthur Kanowitz, Dr. Sarah Kandil, Dr. Edwin Loftin, Dr. Anne Lyren, Dr. Kevin McQueen and Dr. Lauren Berkow. Free CE offered for physicians and nurses. This activity has been approved for AMA PRA Category 1 Credits™ and ANCC contact hours. Registration -
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Social Disparities Webinar (Part II)
Patient Safety Learning posted a calendar event in Community Calendar
The Patient Safety Movement Foundation is proud to partner with MedStar Health to offer free Continuing Education (CE) credit for this patient safety webinar. With Patricia Merryweather-Arges, Dr. Ronald Wyatt, Dr. Daria Terrell, and Dr. Marcus Robinson. M Free CE offered for physicians, nurses, and pharmacists. This activity has been approved for AMA PRA Category 1 Credits™ and ANCC contact hours. Register -
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Inquests, Indemnity and Incidents in Primary Care
Clive Flashman posted a calendar event in Community Calendar
untilThis meeting will focus on some of the key medico-legal issues that impact GPs, primary care and patient safety, with a specific emphasis on inquests, clinical negligence and incidents. This comprehensive programme will review and explore the latest legal and regulatory developments from national leaders in each of these fields. Delegates will gain an understanding of: The role of coroners and inquests, what to expect and what GPs and those working in primary care need to do to prepare and actively learn from deaths The role of Medical Examiners and how they will impact on primary care The support, including education and training, available to GPs in dealing with medico-legal issues and how to access practical support (e.g. via the Medical Defence Organisations) when necessary The role of NHS Resolution and the Clinical Negligence Scheme for GPs (CNSGP) and their impact upon GPs and patient safety Developments in learning from incidents in primary care, including feedback from the CQC regarding best practice and areas for improvement Book here -
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Masterclass: Developing your role as a Senior Information Risk Owner (SIRO)
Patient Safety Learning posted a calendar event in Community Calendar
This masterclass, facilitated by Barry Moult, a former Head of Information Governance for an NHS Trust, and his colleague Andrew Harvey, will focus on developing your role as a SIRO (Senior Information Risk Officer) in health and social care. Further information and to book your place or email kate@hc-uk.org.uk A discount is available to hub members by quoting reference hcuk20psl when booking (cannot be used in conjunction with any other offer; full T&Cs available upon request). -
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Root Cause Analysis: 1 Day Masterclass
Patient Safety Learning posted a calendar event in Community Calendar
This intensive masterclass will provide in-house Root Cause Analysis training in line with The NHS Patient Safety Strategy (July 2019). The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. hub members can receive a 10% discount with code hcuk10psl. Further information and registration -
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RLDatix Palooza
Patient Safety Learning posted a calendar event in Community Calendar
untilBringing together healthcare and patient safety changemakers from across the globe, RLDatix Palooza creates a unique learning environment. With immersive education sessions, enlightening keynotes, healthcare thought leadership panels, interactive hands-on training opportunities and lively evening network activities – this is a conference like no other. You’ll leave with the inspiration (and skills) you need to take your patient safety initiatives to the next level. Registration -
EventuntilBook here Matt Hassan, National Retraining Scheme and National Skills Fund Programme Director, Department for Education Iain Murray, Senior Policy Officer, TUC Nic Trower, Senior Policy Advisor, CBI Juliet Stuttard, Director, PwC UK Patrick Craven, Director of Assessment Policy, Research and Compliance, City & Guilds Dr Fiona Aldridge, Director, Policy and Research, Learning and Work Institute and Kenny Barron, Unite the Union; Joe Billington, National Careers Service; Stephen Cole, CITB; Lesley Giles, Work Advance; Jack Orlik, Nesta; Dr Susan Pember, Holex; Patrick Spencer, Centre for Social Justice; Simon Tindall, The Open University and Paul Warner, Association of Employment and Learning Providers Chaired by: Baroness Garden of Frognal, Deputy Speaker, House of Lords Lord Watson of Invergowrie, Shadow Spokesperson for Education The agenda: What has been learnt from the National Retraining Scheme Creating an effective retraining offer - funding, scope, and engagement with industry and the workforce Case study: international approaches to lifelong learning The role of qualifications in the future lifelong learning landscape Adapting to a changing labour market following COVID-19 - careers advice and guidance, retraining, digital literacy and the impact on labour mobility Lessons from the National Retraining Scheme pilots and user research, and the next steps for the National Skills Fund The discussion will also look ahead to: the role of the NRS in dealing with medium term skills needs following the COVID-19 pandemic the establishment of the Government’s new £2.5bn National Skills Fund prior to an expected consultation on the fund which will look at long term skills needs wider issues around lifelong learning Funding With concerns being raised by some in the sector, and with projected costs for both the National Retraining Scheme and National Skills Fund yet to be outlined - delegates will discuss: cost expectations sources of funding, including the potential balance of contributions from government, employers, and users. Size and scope Discussing what has been learnt so far from the National Retraining Scheme, with: pilots initially focused towards adults in low-skilled work and occupations susceptible to automation the first phase of the Scheme ahead of full rollout available only to adults aged 24 and older, qualified below degree level, and within a certain wage threshold. Inclusivity What will be needed to develop programmes that: adapt to user needs ensures high take-up secures the involvement of hard-to-reach groups serves those who are otherwise unlikely to receive retraining - particularly those lacking the time, money, and the confidence or necessary skills to retrain. Strategic aims How to achieve the overarching objectives of both the NRS and National Skills Fund, for: creating a culture of retraining and lifelong learning overcoming the barriers that adults face to retraining - looking at the roles of: careers advice and guidance - and how it will need to develop qualifications and awarding bodies. The changing skills landscape following the pandemic With the Government increasingly focusing on digital skills across the spectrum, we expect discussion on: the contribution of the National Retraining Scheme to maintaining and updating the digital literacy of the workforce opportunities for retraining in data science and artificial intelligence skills, with plans for this to be supported by the Adult Learning Technology Innovation Fund the shape that the National Skills Fund should take to support long term skills needs following COVID-19 - including how: the Fund can complement existing support which is available support employers - particularly SMEs how the Government can ensure the best possible return on investment. Broader economic impacts With the National Retraining Scheme and National Skill Funds widely considered as a response to work automation, we also expect discussion on: how the programmes can be designed to combat macro-economic challenges, such as skill shortages, productivity issues, and labour mobility examples of how retraining is being approached outside the UK. Developments that are relevant to the discussion: The first phase of the NRS - in the Liverpool City Region, the West Midlands Combined Authority, the Leeds City Region LEP, Cambridgeshire and Peterborough combined authority area, the Heart of the South West LEP and the North East LEP. The forthcoming Government consultation on the establishment of the National Skills Fund with a report by City and Guilds recently calling for government to release and redirect £3bn in funding assigned for the National Skills Fund to support those that have lost their jobs as a result of the COVID-19 pandemic. The announcement by Government of reforms to Higher Technical qualifications to improve support adults seeking to retrain and upskill, including new qualifications from September 2022 with a Government quality mark. Launch of the new digital service ‘Get Help to Retrain’ last year and the recent issuing by Government of a tender as part of the NRS for groups of employers, providers and local authorities to deliver a new training model in the digital sector with the partnership providing 12 week courses.
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Event
Human Factors for Patient Safety Course
Patient Safety Learning posted a calendar event in Community Calendar
Patient Safety is an essential part of health and social care that aims to reduce avoidable errors and prevent unintended harm. Human Factors looks at the things that can affect the way people work safely and effectively, such as the optimisation of systems and processes, the design of equipment and devices used and the surrounding environment and culture, all of which are key to providing safer, high quality care. New for September 2020, this part-time, three year, distance learning course, from the Centre of Excellence Stafford, focuses specifically on Human Factors within the Health and Social Care sectors with the aim of helping health and social care professionals to improve performance in this area. The PgCert provides you with the skills to apply Human Factors to reduce the risk of incidents occurring, as well as to respond appropriately to health, safety or wellbeing incidents. Through the study of Human Factors, you will be able to demonstrate benefit to everyone involved, including patients, service users, staff, contractors, carers, families and friends. Further information -
EventuntilEast London NHS Foundation Trust (ELFT) Quality Improvement (QI) Department is hosting a one-day Pocket QI training. This is an interactive easy to follow introduction to some of the concepts and methods of QI. Join a team of Improvement Advisors who will take you through the fundamentals of QI and how you can make apply the methodology to your personal and professional life. Training will be delivered by ‘Zoom’ video conferencing. Registration
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The Tipping Point of Virtual Care and Rise of Personal Health Data
Clive Flashman posted a calendar event in Community Calendar
untilThis webinar will explore virtual care and the use of patient health data through remote patient monitoring. In the UK and US alike, COVID-19 has accelerated the dramatic shift towards utilising digital health services and tools to virtually connect with and care for patients. Remote patient monitoring (RPM) offers providers the opportunity to remotely collect and utilise patients’ personal health data, such as data from their home-use medical devices and wearables, within care delivery efforts. These personal health data are providing deeper insight into patients’ physiologic health metrics, lifestyle decisions and behavioural trends while replacing the clinical data previously collected in-person. As health care organisations need to quickly scale virtual care to thousands of patients, clear best practices and lessons learned have emerged. This episode will deep-dive into the successful operations of the largest, centralised RPM programme, supporting over 3000 clinicians and more than 50,000 enrolled patients. We’ll delve into the most basic and complex challenges around patient-generated health data, patient consent, enrollment workflows, device logistics, patient and provider engagement, and more. This webinar will explore: Core operations and technologies to a holistic virtual care strategy The clinical outcomes, patient and provider satisfaction, and efficiencies created with RPM Best practices in digital health operations, data integration, analytics, and engagement A model and framework for scaling virtual care and RPM to thousands of patients quickly A CPD certificate with 1 CPD credit will be issued to those joining the webinar live as well as those who watch the recording afterwards. Certificates will be issued 7 days after the webinar to those who watch it live and after 30 days for those that watch the recording. Join in the conversation online using #RSMDigiHealthBook hereFollow us on Twitter: @RoySocMed Book here -
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