Patient Safety Matters
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Patient Safety Matters
Learning how to manage risk and prevent harm to patients.
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Was it Really a Miracle on the Hudson? Aviation meets healthcare safety (NPSF, May 2012)

Plenary presentation at National Patient Safety Foundation's 2012 Meeting on May 24, 2012. Jeff Skiles, First Officer of US Airways Flight 1549, and Rollin "...
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Watch this! You will not regret spending 75 minutes watching these two experts give a very engaging presentation. One of their core messages is that accountability and patient safety systems should be separated. We truly need a no blame culture. This seems to be slightly more controversial than I first thought.

There are many, many more wonderful insights within this. 

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17 Minutes on Vimeo

This is "17 Minutes" by Social Media and Critical Care on Vimeo, the home for high quality videos and the people who love them.
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Just saw this tweeted by @HeatherM211  - a powerful story told by parents and their son about what can go wrong and why... We need to develop our non-technical skills just as much as our technical ones. 

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Human Factors and Non-technical Skills

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This is a short introduction to these key areas for our #cdfmed medical students

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Rhona Flin: building a safety culture in the NHS

Rhona Flin, Professor of Applied Psychology at the University of Aberdeen, discusses how we can develop and manage a safety culture in the NHS and draws on how
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From the King's Fund day on the Francis inquiry. Flin is a renowned expert on human factors. She has some criticism of NHS leadership programmes in here- thety need to focus more on safety. 

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Sidney Dekker on Just Culture

Human Factors and System Safety, Leading Opinion from Professor Sidney Dekker. Explains Just Culture; why you need it, what it is, and how you get it.
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In light of the Francis Inquiry you have probably heard of 'just culture'. Here Dekker gives a brief introduction. 

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Implementing human factors in healthcare

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Very good resource. 

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BBC Two - Horizon, 2013-2014, How to Avoid Mistakes in Surgery

BBC Two - Horizon, 2013-2014, How to Avoid Mistakes in Surgery | Patient Safety Matters | Scoop.it

What can surgeons learn from other professions about making life or death decisions? 

Anne Marie Cunningham's insight:

You can watch the video on YouTube now but there is some interesting background here. 

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AnneMarie Cunningham's curator insight, May 23, 2013 12:56 PM

Unfortunately this is no longer on iPlayer but there are some clips available at thsi link. 

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Smart Nursing: Nurse Retention & Patient Safety Improvement... : Clinical Nurse Specialist

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Last year, a new study by the University of Pennsylvania found that poor management of staff, whether a shortage of critical nurses or the inability to foster a collaborative work environment, is leading to significant work-overload and burnout.

The researchers found that if hospitals reduced nursing burnout from 30 percent to 10 percent, 4,160 cases of hospital-acquired infections could be prevented annually, saving $41 million. Earlier, the same set of researchers found that if Pennsylvania enacted and enforced a minimum nurse-to-patient ratio as California has done, as many as 264 surgical deaths could have been prevented in 2010.

Anne Marie Cunningham's insight:

There is lots of discussion about mandating nurse-patient ratios in the UK. It seems that this is an issue in the US as well. Will they adopt legislation on this? This short article mentions some of the research which suggests it is a good idea.

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Autonomy, aviation and #ptsafety (with tweets) · amcunningham

What can the 'miracle on the Hudson' story tell us about autonomy in #ptsafety in healthcare?
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I am no expert on patient safety but in the past few weeks I have been learning a lot. This storify documents the conversation that started of this latest learning journey.I'm coming across so many good resoiurces that I decided a new scoopit to curate them would be useful.

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Wrongfooted (with images, tweets) · traumagasdoc

how failure of process and inadequate WHO checklist participation led to the wrong foot being operated on.
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@traumgasdoc's viral #ptsafety story 

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BBC Horizon 2013 - How to Avoid Mistakes in Surgery

Dr Kevin Fong finds out how doctors can avoid making mistakes in the high-pressure, high-stakes world of the operating theatre.

He sets out to learn how other professionals make life and death decisions under pressure, from airline pilots facing emergencies, to the Fire Service dealing with lethal blazes, to the world of Formula One pit crews. Kevin discovers how all these fields are helping to make surgery safer

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This is no longer on BBC iPlayer bit someone added to YouTube- handy! 

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Robert Francis: lessons from Stafford

Robert Francis QC presents the lessons from his inquiry into care failings at Mid Staffordshire NHS Foundation Trust.
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9 minutes of Francis on Francis. Contains some excerpts of staff testimonies including the consultant who didn't raise any alert in case it impacted on his discretionary awards.

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Improving safety in primary care

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From the Health Foundation, a review of the literature on patient safety in primary care.

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X.M. Meijome's curator insight, July 8, 2013 4:01 AM

Documento de la fundación para la salud del R.U. sobre #SegPac en AP

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Just A Routine Operation

As a result of his personal experience, Martin Bromiley founded the Clinical Human Factors Group in 2007. This group brings together experts, clinicians and enthusiasts who have an interest in placing the understanding of human factors at the heart of improving patient safety.

In Just A Routine Operation Martin talks about his experience of losing his wife during an apparently routine procedure and his hopes for making a change to practice in healthcare.

This film was produced by thinkpublic for the NHS Institute for Innovation and Improvement

Anne Marie Cunningham's insight:

I saw this video for the first time yesterday in a workshop on teaching human factors at #NorthernMedEd. It is incredibly powerful.

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Family's tragedy leads to patient-safety app

Family's tragedy leads to patient-safety app | Patient Safety Matters | Scoop.it

The foundation's newest tool is a patient-safety iPad app that became available for purchase on iTunes in mid-March for $2.99. The Batz Guide for Bedside Advocacy App, designed with help from doctors and health care experts across the country, allows patients and their families to monitor medical care to improve safety. Patients and families can log medications, track vital signs, look up medical terms follow presurgery and post-surgery checklists and more.

Anne Marie Cunningham's insight:

I haven't explored the app but this is a very interesting move in patient safety- empowering patients and carers to be involved.

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Behaviour Change Toolkit — Bradford Institute for Health Research

Behaviour Change Toolkit — Bradford Institute for Health Research | Patient Safety Matters | Scoop.it
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I came across this through Twitter. If you have watched Terry Fairbanks talk you will know that he strongly advocates looking at the system rather than individuals to improve patient safety. It seems to me that the Behaviour Change Toolkit is all about changing the behaviour of individuals. For example, there is a questionnaire about why people refer for xray to conform NG tube placement rather than do pH testing. I would have thought the simplest way to address this would be to ask "Why do you refer for CXR rather than do pH testing?" But there is no room for free text response. All responses are by Likert scale. So if the issue is that people don't know where to get pH tests etc then it will not be discovered by this questionnaire. To me, this seems unlikely to identify local barriers to perform target behaviour at a system level. What do you think? Is our approach to patient safety in the UK still to focussed on individual behaviour? 

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