Lorraine S.’s Post

Part 2- Reflecting on M&M Rounds cont... Key Qs! Safety I – Patient Safety Incidents (PSIs) with poor outcome 😤 1. Clinical practice and patient care - What are the most important takeaways from this case in terms of improving patient care next time? 2. Systemic issues - Were there any systemic issues or barriers that contributed to the adverse outcome? - What changes in hospital policies or procedures could help prevent similar occurrences in the future? 3. Communication and teamwork - How effective was the communication among the team during this case? - Are there any improvements in teamwork or communication that could have altered the outcome? 4. Education - What educational opportunities we can learn from this case? - Are there specific areas where additional training or resources are needed to prevent similar outcomes? 5. Recommendations - What specific recommendations can we make based on this case? 6. Reflection - How can we apply the lessons learned from this case to other areas of our practice? Safety II – When Things Go Well!!! 🙌 1. Clinical practice and patient Care - What aspects of clinical practice worked well in this case, and what contributed to success? - How can we replicate these successful strategies in future cases? 2. Systemic issues - What changes in hospital policies or procedures could help ensure that successful outcomes continue to occur? - Were there any resources that contributed to the positive aspects of this case? 3. Communication and teamwork - How did effective communication among the team contribute to the positive outcome of this case? - What teamwork strategies were particularly effective, and how can we implement these consistently? 4. Education and training - What educational opportunities does this case present for our staff, focusing on what went well? - Are there specific training programs or resources that helped achieve the positive outcome? 5. Recommendations and action items - Based on the successes of this case, what specific recommendations can we make to enhance patient safety and care quality? 6. Reflection - How can we apply the lessons learned from this case to other areas of our practice, particularly those related to success? By reflecting this way, we can improve the way M&M rounds are conducted. This approach encourages open discussions about both failures and achievements, fostering a culture of continuous learning and improvement. Additionally, it encourages more people to come forward and share their experiences. Should we give it a go? #PatientSafety #VeterinaryEducation #MMrounds #ContinuousImprovement #SafetyCulture #ProfessionalDevelopment

Patient Safety Structural Measure Domain 2: Strategic Planning & Organizational Policy Implementation of a patient safety curriculum and competencies for all clinical and non-clinical hospital staff, including C-suite executives and individuals on the governing board ECRI, together with our affiliate, the Institute for Safe Medication Practices (ISMP), a global leader in medication safety, offer healthcare teams a comprehensive curriculum of training and professional development opportunities including competency -based training for medication safety, root cause analysis, human factors and safety systems design, psychological first aid training, and more. Learn more: https://hubs.la/Q02M5zSL0 #patientsafety #healthcaresafety #riskmanagement #safety #risk #quality

Are you satisfied that your hospital’s root cause analysis process is actually preventing harm from reoccurring? Are the RCA team members effectively trained to do this important work? Our ECRI team of certified Patient Safety Advisors works with hospitals to implement the elements of the CMS Patient Safety Structural Measure. We use a unique approach, based on advanced safety science and human factors engineering, to create a programmatic foundational patient safety management program! Let us know how we can help your team! #trustedvoice #patientsafety

World Patient Safety Day 2024: A Call to Action for Medical Personnel. Today, we are reminded of the immense responsibility we hold as healthcare professionals. Patient safety is not just a part of our duty—it is the core of our practice. Every decision, every action, and every interaction has the potential to impact the safety and well-being of those we care for. Promoting patient safety requires: 1. Clear Communication: Ensure open, clear, and empathetic communication with patients and their families. It’s crucial to inform them about their condition, treatment options, and potential risks. A well-informed patient is empowered and less likely to experience errors. 2. Team Collaboration: Healthcare is a team effort. Collaborate and communicate with your colleagues to ensure continuity of care. Encourage a culture where everyone feels comfortable raising concerns or suggesting improvements. 3. Continuous Learning: Medicine is ever-evolving, and so should we be. Stay updated with the latest protocols, safety guidelines, and evidence-based practices. This is especially important in recognizing and preventing medical errors. 4. Patient Involvement: Involve patients in their care decisions. Listen to their concerns, respect their choices, and engage them as active participants in their care. The more engaged they are, the safer they will feel. 5. A Culture of Accountability: Acknowledge when mistakes occur, and use them as learning opportunities. Creating a non-punitive environment where mistakes are discussed openly leads to better safety outcomes. We need to commit to fostering a culture where safety is prioritized, learning is continuous, and the patient’s voice is always heard. Let’s do better to minimize risks and deliver the highest quality care! Together, we’ll continue our journey of putting patient safety first, today and every day. #WorldPatientSafetyDay #Healthcare #PatientSafety #MedicalProfessionals #ContinuousImprovement #Teamwork

Are you involved in recruiting or managing Patient Safety Partners? In a recent workshop, Patient Safety Learning and Aqua spoke to Patient Safety Partners and their managers about 'what good looks like'. We're sharing their insights in a series of blogs. This is the second blog and focuses on recruitment and induction. We hope this will help both organisations and Patient Safety Partners embed the role well. https://lnkd.in/entxM-jm #patientsafety #patientleadership

🌟 Celebrating Patient Safety Awareness Week! 🌟 As we mark Patient Safety Awareness Week, I invite you to join me in reflecting on our journey toward safer health care. This week serves as a powerful reminder of the critical importance of patient safety for both our patients and the dedicated workforce who serves them. 🌐 Why a Focus on Safety?: While we’ve made significant strides in patient safety over the past two decades, the sobering reality remains: medical harm continues to be a leading cause of death worldwide. The World Health Organization estimates that 134 million adverse events occur annually due to unsafe care in hospitals in low- and middle-income countries, resulting in approximately 2.6 million deaths. Closer to home, as many as 250,000 to 400,000 deaths occur each year in the United States due to errors or preventable harm. These incidents not only impact lives but also ripple through families, affecting physical health, emotional well-being, and financial stability. 🌱 Our Collective Responsibility: Preventing harm in healthcare is a public health imperative. Every one of us interacts with the healthcare system, so therefore we all have a role to play in advancing safer health. As we celebrate the progress we’ve made, let’s also acknowledge that there’s still much more to accomplish. 🔍 Explore Additional Training Opportunities: Now more than ever we need healthcare leaders who have the skills to lead effective change in their organizations. I highly encourage any healthcare leader looking to make a positive impact to explore two exceptional programs at Harvard Medical School that I’m proud to be a part of for additional training: 1.    #SQIL (Safety, Quality, Informatics, and Leadership): a 1-year certificate program that equips leaders with the knowledge and skills needed to drive transformative change in healthcare safety and quality. It’s a dynamic blend of evidence-based practices, informatics, and leadership principles. 2.    #MHQS (Master of Science in Healthcare Quality and Safety): MHQS is a comprehensive master’s program designed for professionals committed to elevating patient care. Participants delve into quality improvement methodologies, patient-centered approaches, and the latest advancements in safety science. 🌟 Let’s Keep Moving Forward: During this Patient Safety Awareness Week, let’s celebrate our progress, honor the tireless efforts of our healthcare heroes, and recommit ourselves to the pursuit of safer care. Together, we can create a world where every patient receives care that is not only effective but also free from harm. #PatientSafety #HealthcareQuality #HealthcareLeadership #Harvard #harvardmedicalschool Harvard Medical School Postgraduate Medical Education https://lnkd.in/eCkpKvDD

Genuinely blown away by this new book. Patient Safety: Emerging Applications of Safety Science. 11 chapters describing the most up to date approaches to learning and improving patient safety. I was so pleased to be asked to write the chapter on After Action Review, to share what I and others have learned. Obviously, my chapter is a good one, 😀 with Katy Fisher and Lisa Moss contributing excellent case studies, but so are all the others!   In Chapter 10 Dr Samantha Machen covers the why, what and how of Thematic Reviews I found Mark Sujan’s writing about Safety 11 in Chapter 5 especially interesting. And the chapter on “Patient and Family Engagement Following Patient Safety Incidents” written by several experts in this area is incredibly helpful in articulating the issues involved.  Why don’t you see for yourself. Click on the link here to order your own copy. https://lnkd.in/g-MD75HP

An interesting read from the Guardian highlighting the importance, and challenges, of clinical safety assurance: https://zurl.co/rcPY. Our CSO, joe horne has provided some insight on his experience of working with colleagues within the NHS to deliver digital clinical safety assurance: “I work closely with NHS trusts that face a shortage of dedicated Clinical Safety Officer time; I also provide support to suppliers seeking clinical safety assurance to meet regulatory compliance. One recurring challenge I've observed is that clinical safety often plays a secondary role in both the development (DCB0129) and implementation (DCB0160) phases of projects. Ring-fencing time for Clinical Safety Officers can be a challenge due to capacity pressures on the NHS which can leave deployments vulnerable, with limited oversight of potential safety risks and their long-term consequences. While we have mandated standards and requirements in place, it requires resource to continually audit and maintain clinical safety assurance and as a result potentially avoidable risks can become reality. The pressing question is: how do we elevate the standard of clinical safety across the board, ensure consistency among providers, and prevent further financial drain by keeping clinical safety assurance processes within the NHS?" We'd love to hear of your experience with digital clinical safety and its consideration. Do you feel that clinical safety has the appropriate focus and resource?

DHSC have launched a consultation on the standards….More training and tweaks to templates will likely be recommended which IMO is kicking the can down the road. Compliant suppliers should be rewarded and those that don’t take safety seriously held to account by regulators. Every trust needs a confident CSO that can balance risk and delegate. Until Digital Clinical Safety are part of audit attached to £££ CS will not be a priority.

Testing knowledge and hardwiring adoption of Patient Safety behaviors. I was once asked how we could measure patient safety. I responded that a focus on harm events, good catches/ near miss event reporting, sharing lessons learned, and periodically reevaluating actions to prevent reoccurrence would support our goals. However, the executive to whom I reported at the time insisted that we do weekly testing throughout organization on the safety behaviors and use the compliance/scores as a scorecard measurement. I disagreed concerned that this approach would harm our efforts to improve patient safety, as it was not aligned with the principles of adult learning. Regardless, the executive made the decision and weekly tests were deployed. Unfortunately, the approach backfired and created tremendous organizational animosity from the care providers who were required to take those weekly tests and the approach did not produce the intended knowledge or utilization of the patient safety behaviors. Share with me your approaches and success stories. How has your organization hardwired learning and adoption? What has worked and what has not?