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Showing results for tags 'Communication'.
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Content ArticleAll human activity, along with associated emergent problematic situations and opportunities, is embedded in context. The ‘context’ is, however, a a melange of different contexts. In our attempts at understanding and intervening, rarely do we spend much time trying to understand context, especially as it applies to the current situation, and how history has influenced where we are. Instead, we tend to: a) make assumptions about context, but not make these explicit, resulting in different unspoken and untested assumptions; b) limit contextual analysis to proximal, ‘obvious’ or uncontroversial aspects; or c) jump to a potential solution (or a way to realise an opportunity), shortly followed by planning for this intervention (which has the important function of helping us to feel in control, thus relieving our anxiety – at least temporarily). An approach Steven Shorrock has found useful is to spend time considering contextual influences (e.g., on decision making, at multiple levels of organisations) on problematic situations or potential solutions, more explicitly. He shares this in his latest blog.
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Content Article
Rethinking Patient Safety: Maternity safety (4 October 2020)
Patient Safety Learning posted an article in Maternity
Suzette Woodward reflects on the recent reports and research into maternal safety and why we need to shift to a Safety II approach. -
Content ArticleThis systematic review in The Journal of Advanced Nursing aimed to synthesise current knowledge about the impact of safety briefings on improving patient safety. The authors found that safety briefings achieved beneficial outcomes and can improve safety culture. Beneficial outcomes included: improved risk identification. reduced falls. enhanced relationships. increased incident reporting. ability to voice concerns. reduced length of stay.
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News Article
Patients left 'in limbo' by NHS virus response
Patient Safety Learning posted a news article in News
The stress and anxiety caused to patients by "poor communication" from NHS bodies in England during the covid pandemic has been criticised by MPs. While recognising the huge burden placed on the NHS, their report said cancelled treatments and surgery had left some "in limbo" and others "too scared" to seek medical help. The report also questioned why weekly testing of NHS staff had not yet begun. And it called for their mental and physical wellbeing to be supported. Jeremy Hunt, who chairs the Health and Social Care Committee, which compiled the report, praised the "heroic contribution" made by front-line NHS staff during the pandemic, which had saved many lives. But he said the pandemic had "massively impacted normal NHS services" and this situation could have been improved with clearer communication to patients and better infection control measures in hospitals. The report, based on evidence from doctors, nurses, patient groups and NHS leaders, said the case for routine testing for all NHS staff in all parts of the country was "compelling" and it should be introduced as soon as possible before winter to help reduce the spread of the virus. The government and NHS England told the committee they wanted to bring in routine testing of staff but any plans depended on the capacity available. Read full story Source: BBC News, 1 October 2020 -
Content ArticleAlthough airway safety is known to be one of the key components in safe care, thousands of patients lose their lives each year to poor airway management and unplanned extubations. In this Patient Safety Movement webinar, the team discusses starting an unplanned extubation project without buy-in from others, multi-institutional collaboration, pushback from leaders, colleagues, or other organisations, the future of interventions, clinicians who have experience with unplanned extubations as key advocates, and cross-checking pediatric and adult safety efforts. The panel ends with Drew Hughes’ story and the team emphasises taking a moment to ground yourself in your practice and the importance of speaking up when you think the patient is at risk.
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EventuntilIt is no longer enough just to have a good idea; just as important is the ability to work collaboratively with others, to navigate organisational politics and to work with relational dynamics to use that idea to create change. In the midst of a global pandemic, where new organisational arrangements have changed familiar lines of authority and where leadership takes place predominantly from behind a computer screen, opportunities for influencing can be fraught with dilemmas and frustrations as well as bringing opportunities for innovation and new ways of working. This programme from the King's Fund will enable you to work more effectively in the gap between your commitment and enthusiasm for change and the reality of making things happen within the constraints of your role and wider system priorities. The ongoing response to COVID-19 and uncertainties about the coming months have brought an added layer of anxiety and complexity to the role of leaders, with familiar tactics and assumptions about leadership being challenged in this unprecedented environment. This programme will offer a reflective space to support you in taking stock, providing an opportunity to review your learning about leadership in the current context, and will help prepare you for working well in the coming months. It will enable you to work with the complexity of relationships within teams and across organisations, and will help you to develop a language and conceptual base in order to make sense of the nuances in today’s health and care systems. Further information and registration
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Content ArticleInfographic from the Patient Safety Movement on what is needed when a patient is harmed and why we need to involve patients and families throughout the process.
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Content ArticleThe Association of Anaesthetists has published two posters highlighting what to do if you see unprofessional behaviours to make hospitals safer for patients and staff.
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Content ArticleThe World Health Organization designated September 17 as World Patient Safety Day — a day, every year, to raise awareness of healthcare safety and reiterate its importance. This year the Patient Safety Movement hosted a four-hour virtual event as part of their #uniteforsafecare public awareness campaign. They organised the event to bring the public into the fold as well as unite patients, advocates, health workers and leaders together globally — working to ensure patient and health worker safety internationally. Here are 11 takeaways for the public, patients and their families from the #uniteforsafecare virtual event.
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Content ArticleWhy is it hard for a highly trained professional to speak or report about mistakes made by him or her? Jean-Pierre Kahlmann, a retired Military and Airline Pilot, and now Co-owner and CEO of Yes Human Factors Ltd, believes that every staff member in an organisation should feel safe to use her or his voice to speak about safety issues, mistakes and how to learn and improve. In this TEDx presentation, Jean-Pierre takes you on a trip through his Airforce and civil aviation career to show the added value of Just Culture in high reliability organisations. He talks about his, initial, internal resistance against speaking about his mistakes and he sees the same resistance within the culture of health care professionals.
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Content ArticleBubble PAPR is an innovative PPE respirator designed to keep NHS staff safe while caring for patients during COVID-19. In this video, Brendan McGrath, an NHS Intensive Care Consultant, describes how Manchester University Foundation Trust, Manchester University and Designing Science Ltd came together to re-invent the Powered Air Purifying Respirator for the covid era.
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Content ArticleSarah Seddon's son (Thomas) was stillborn in May 2017. The lack of candour following Thomas’ death and the conduct of the serious incident investigation impacted significantly on Sarah and her family. The local investigation was followed by a Fitness to Practise (FtP) investigation where Sarah experienced how damaging, dehumanising and traumatic FtP processes can be for patients who are required to be witnesses. Here she reflects on the impact of being a witness in a Fitness to Practise (FtP) hearing had on her.
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Content ArticleThis systematic review in BMJ Quality & Safety looks at existing research into the impact of hospital-based safety huddles. The authors found that while there are many anecdotal accounts of successful huddle programmes, there is not yet much high-quality peer-reviewed evidence regarding the effectiveness of hospital-based safety huddles. They suggest that additional rigorous research is needed to enhance collective understanding of how huddles impact patient safety and other outcomes. The review proposes a taxonomy and standardised reporting measures for future studies, to enhance comparability and evidence quality.
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Content ArticleThe COVID-19 pandemic has had one of the biggest effects on work-as-done in healthcare in living memory. So what might we learn about work from the perspectives of frontline workers? Steven Shorrock asked a variety of practitioners to give a short answer – whatever came to mind. The themes that emerge centre around people, their activities, their contexts, and their tools. Many insights concerned the varieties of human work, goal conflicts, design, training, communication, teamwork, social capital, leadership, organisational hierarchy, problem solving and innovation, and – generally – change. Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives.
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Content ArticleIn her guest blog for the Professionals Standard Body (PSB), Sarah Seddon talks about the Duty of Candour and how it's affected her personal life.
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Content ArticleIn the aftermath of an adverse event, an apology can bring comfort to the patient, forgiveness to the health practitioner, and help restore trust to their relationship. According to the Health and Disability Commissioner: "The way a practitioner handles the situation at the outset can influence a patient's decision about what further action to take, and an appropriate apology may prevent the problem escalating into a complaint to HDC". Yet, for many health practitioners saying "I'm sorry" remains a difficult and uncomfortable thing to do. We can help to bring down this wall of silence by developing a clear understanding of the importance of apologies to patients and health practitioners; appreciating the difference between expressing empathy and accepting legal responsibility for an adverse outcome; knowing the key elements of a full apology and when they should be used; and supporting those who have the honesty and courage to say "I'm sorry" to patients who have been harmed while receiving healthcare.
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Content ArticleThe Health Service Executive (HSE) Dublin North East’s Patient Safety Tool Box Talks have been developed to assist with the delivery of key patient safety messages within the workplace. Patient Safety Tool Box Talks© are not a substitute for formal training but rather recognises the need to embed patient safety into the workplace and as such are a support to formal more detailed training programmes. This approach allows the delivery of consistent short customised patient safety messages to staff in a brief intervention as part of a team meeting or at a shift change. The talks are designed to take no more that 5-10 minutes to deliver are capable of being delivered by a non-specialist. If questions however arise beyond the scope of the talk these should be referred to a specialist for clarification. This Tool Box also contains Guidance on Delivering a Patient Safety Tool Box Talk© and a number of talks on a variety of safety topics.
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Content ArticleDo patients’ and families’ experiences with communication-and-resolution programmes suggest aspects of institutional responses to injury that could better promote reconciliation after medical injuries? This interview study of 40 patients, family members, and hospital staff in Australia found that patients have a strong need to be heard after medical injury that is often unmet. Although 18 of 30 patient and family participants (60%) reported positive experiences with communication-and-resolution programmes overall and continued to receive care at the hospital, they reported that hospitals rarely communicated information about efforts to prevent recurrences. Opportunities are available to provide institutional responses to medical injuries that are more patient centred.
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Content ArticleAn educational session from The Association for Perioperative Practice (AfPP) dedicated to the dangers of noise and distraction in healthcare with a possible solution, Below Ten Thousand. Below Ten Thousand is a language-based safety tool for any clinical arena where 'noise and distraction' is a problem, and where high performance teams need to quickly gain 'situational awareness' and ‘directed focus’ in order to successfully navigate the perils of acute healthcare whilst providing first class interventions.
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Content ArticleIt is often the case that particular healthcare policies and practices change overnight from being discouraged or even forbidden to becoming more or less compulsory. An example of this is the change in how patients can access doctors during the coronavirus pandemic. At the end of July, Matt Hancock gave a speech on the future of healthcare in which he declared “… from now on, all consultations should be teleconsultations unless there is a compelling reason not to.” The following day, Sir Simon Stevens’ letter on the third phase of the NHS response to COVID-19 gave more nuanced messages and acknowledged the place of face to face consultations alongside digital and telephone consultations in some circumstances. Meanwhile, a recent RCGP survey reported that at the present time 61% of appointments are full telephone consultations and 16% are telephone triages. Many changes in how patients can access doctors have the potential to offer great benefits to patients and to ease pressures on health systems; however, what is right in some circumstances is not right for all as Ros Levenson, Chair of Academy Patient and Lay Committee, Academy of Medical Royal Colleges, discusses in her blog.
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Content Article
David Oliver: Should doctors be on first name terms?
Patient Safety Learning posted an article in Culture
In this BMJ perspective, David Oliver, a consultant in geriatrics and acute general medicine, discusses whether doctors should keep with tradition of using their professional titles amongst colleagues and patients, or whether, as in his own hospital, first names should be used as part of a wider focus on patient safety and a human factors culture. Of course, professional roles and hierarchies remain important in healthcare. Different people have different training or experience, and it’s important to have clear team leadership and responsibilities, especially in emergency care. But first names are part of a push to build strong team working, flatten hierarchies, and improve patient safety by making it easier for less senior team members or different clinical professionals to question senior doctors and “stop the line” before avoidable harm occurs. -
Content Article17 September 2020 marks the second annual World Patient Safety Day. The theme this year is 'Health Worker Safety: A Priority for Patient Safety'. In the run up to this special event, Patient Safety Learning are publishing a series of interviews with staff from across the health and care system to highlight key issues in staff safety and gain a clearer idea of the kind of change that needs to take place to keep staff, and ultimately patients, safe. In this joint interview, Patient Safety Learning speaks to Rob Tomlinson, a nurse in the operating theatres at East Lancashire Hospitals Trust, and Peter Smith, now retired after enjoying a thirty-year career in operating theatre nursing. Rob and Pete discuss why staff need to feel both physically and psychologically safe in the operating theatre and empowered to speak up, and how the Below Ten Thousand language tool has made a huge difference in creating a safer operating environment.
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Content ArticleHealthcare organisations are designed to achieve consistent and reproducible outcomes when faced with planned, predictable or ‘routine’ emergencies. Unfortunately, the more robust the system, the less agile it is when faced with a novel clinical crisis. This is not surprising, as it is impossible to create emergency operating procedures for every new or unforeseen catastrophe. Similarly, many surgeons in positions of leadership have limited exposure to executive decision-making or clinical expertise outside their area of specialist training. It is not unreasonable therefore for surgical leaders and their organisations to feel overwhelmed by complex and evolving crises, such as the recent COVID-19 pandemic. At such times, it is important to reflect on key strategies that can provide pragmatic, timely and cohesive means of restructuring the delivery of surgical care at an organisational level.
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Content ArticleDr Abdulelah Alhawsawi, Abdominal Organs Transplant and Hepato-biliary Surgeon, and Director General of the Saudi Patient Safety Center, discusses why hospitals are falling short of safe care levels. He believes healthcare continues to be structurally weak when it comes to the safety conditions and suggests that there is an urgent need for a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. In his essay, Dr Alhawsawi proposes four practical solutions.
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Content Article
Patient Safety Authority: Health literacy
Patient Safety Learning posted an article in Improving patient safety
Structuring and presenting healthcare information that aligns with a patient’s level of understanding can help patients achieve optimal outcomes. Verbal communication strategies such as “teach back” and “Ask Me 3®” programmes and written strategies address opportunities identified in the event reports and may help improve patient understanding and engagement in their care. The Patient Safety Authority have collated guidance, resources and education tools on health literacy.
