Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

Understanding and responding when things go wrong: key principles for primary care educators

Learning from events with unwanted outcomes is an important part of workplace based education and providing evidence for medical appraisal and revalidation. It has been suggested that adopting a ‘systems approach’ could enhance learning and effective change. We believe the following key principles should be understood by all healthcare staff, especially those with a role in developing and delivering educational content for safety and improvement in primary care. When things go wrong, professional accountability involves accepting there has been a problem, apologising if necessary and committing to learn and change. This is easier in a ‘Just Culture’ where wilful disregard of safe practice is not tolerated but where decisions commensurate with training and experience do not result in blame and punishment. People usually attempt to achieve successful outcomes, but when things go wrong the contribution of hindsight and attribution bias as well as a lack of understanding of conditions and available information (local rationality) can lead to inappropriately blame ‘human error’. System complexity makes reduction into component parts difficult; thus attempting to ‘find-and-fix’ malfunctioning components may not always be a valid approach. Finally, performance variability by staff is often needed to meet demands or cope with resource constraints. We believe understanding these core principles is a necessary precursor to adopting a ‘systems approach’ that can increase learning and reduce the damaging effects on morale when ‘human error’ is blamed. This may result in ‘human error’ becoming the starting point of an investigation and not the endpoint

Towards standardisation of no fault found taxonomy

There is a phenomenon which exists in complex engineered systems, most notably those which are electrical or electronic which is the inability to diagnose faults reported during operation. This includes difficulties in detecting the same reported symptoms with standard testing, the inability to correctly localise the suspected fault and the failure to diagnose the problem which has resulted in maintenance work. However an inconsistent terminology is used in connection with this phenomenon within both scientific communities and industry. It has become evident that ambiguity, misuse and misunderstanding have directly compounded the issue. The purpose of this paper is to work towards standardisation of the taxonomy surrounding the phenomena popularly termed No Fault Found, Retest Okay, Cannot Duplicate or Fault Not Found amongst many others. This includes discussion on how consistent terminology is essential to the experts within organisation committees and, to the larger group of users, who do not have specialised knowledge of the field

A safer place for patients: learning to improve patient safety

1 Every day over one million people are treated successfully by National Health Service (NHS) acute, ambulance and mental health trusts. However, healthcare relies on a range of complex interactions of people, skills, technologies and drugs, and sometimes things do go wrong. For most countries, patient safety is now the key issue in healthcare quality and risk management. The Department of Health (the Department) estimates that one in ten patients admitted to NHS hospitals will be unintentionally harmed, a rate similar to other developed countries. Around 50 per cent of these patient safety incidentsa could have been avoided, if only lessons from previous incidents had been learned. 2 There are numerous stakeholders with a role in keeping patients safe in the NHS, many of whom require trusts to report details of patient safety incidents and near misses to them (Figure 2). However, a number of previous National Audit Office reports have highlighted concerns that the NHS has limited information on the extent and impact of clinical and non-clinical incidents and trusts need to learn from these incidents and share good practice across the NHS more effectively (Appendix 1). 3 In 2000, the Chief Medical Officer’s report An organisation with a memory 1 , identified that the key barriers to reducing the number of patient safety incidents were an organisational culture that inhibited reporting and the lack of a cohesive national system for identifying and sharing lessons learnt. 4 In response, the Department published Building a safer NHS for patients3 detailing plans and a timetable for promoting patient safety. The goal was to encourage improvements in reporting and learning through the development of a new mandatory national reporting scheme for patient safety incidents and near misses. Central to the plan was establishing the National Patient Safety Agency to improve patient safety by reducing the risk of harm through error. The National Patient Safety Agency was expected to: collect and analyse information; assimilate other safety-related information from a variety of existing reporting systems; learn lessons and produce solutions. 5 We therefore examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. Key parts of our approach were a census of 267 NHS acute, ambulance and mental health trusts in Autumn 2004, followed by a re-survey in August 2005 and an omnibus survey of patients (Appendix 2). We also reviewed practices in other industries (Appendix 3) and international healthcare systems (Appendix 4), and the National Patient Safety Agency’s progress in developing its National Reporting and Learning System (Appendix 5) and other related activities (Appendix 6). 6 An organisation with a memory1 was an important milestone in the NHS’s patient safety agenda and marked the drive to improve reporting and learning. At the local level the vast majority of trusts have developed a predominantly open and fair reporting culture but with pockets of blame and scope to improve their strategies for sharing good practice. Indeed in our re-survey we found that local performance had continued to improve with more trusts reporting having an open and fair reporting culture, more trusts with open reporting systems and improvements in perceptions of the levels of under-reporting. At the national level, progress on developing the national reporting system for learning has been slower than set out in the Department’s strategy of 2001 3 and there is a need to improve evaluation and sharing of lessons and solutions by all organisations with a stake in patient safety. There is also no clear system for monitoring that lessons are learned at the local level. Specifically: a The safety culture within trusts is improving, driven largely by the Department’s clinical governance initiative 4 and the development of more effective risk management systems in response to incentives under initiatives such as the NHS Litigation Authority’s Clinical Negligence Scheme for Trusts (Appendix 7). However, trusts are still predominantly reactive in their response to patient safety issues and parts of some organisations still operate a blame culture. b All trusts have established effective reporting systems at the local level, although under-reporting remains a problem within some groups of staff, types of incidents and near misses. The National Patient Safety Agency did not develop and roll out the National Reporting and Learning System by December 2002 as originally envisaged. All trusts were linked to the system by 31 December 2004. By August 2005, at least 35 trusts still had not submitted any data to the National Reporting and Learning System. c Most trusts pointed to specific improvements derived from lessons learnt from their local incident reporting systems, but these are still not widely promulgated, either within or between trusts. The National Patient Safety Agency has provided only limited feedback to trusts of evidence-based solutions or actions derived from the national reporting system. It published its first feedback report from the Patient Safety Observatory in July 2005

Racial Conflicts In Schools

That racially motivated conflicts occur in schools is an indisputable fact that becomes evident upon review of both academic literature and popular media. Events such as the Jena 6 incident (Maxwell & Zehr, 2007), school wide racially motivated riots (latimes.com), and court rulings (theithican.org) are distressing examples that racial barriers are real and potentially dangerous for many students in this country. However, little is written about the nature of racial conflicts, including the actual process school leaders engage in when determining how or even whether to intervene in racial conflicts, and the affect those racial conflicts have on the school climate and relevant stakeholders (e.g. directly involved students, other students, and school staff). To address this concern the current study is designed to provide insight into the decision-making process of school counselors in the intervention of racial conflicts that occur between students. The findings of this study will be pertinent and beneficial to all educational professionals as well as students. The following review provides context for understanding racial conflicts in schools, and addresses such issues as prevalence rates, causes, consequences, theories, and interventions to address such conflicts. Finally, the review concludes with a description of limitations in the research and a description of a proposed study

Advancing Patient Safety in the U.S. Department of Veterans Affairs

As part of a systemwide transformation, the VA formed its National Center for Patient Safety to foster an organizational culture of safety within its nationwide network of hospitals and outpatient clinics. A recent medical team training program designed to improve communication among operating room staff was associated with a reduction in surgical mortality and improvements in quality of care, on-time surgery starts, and staff morale. The program is now being expanded to other clinical units, along with a patient engagement program that prevents errors by facilitating communication relating to patients' daily care plans. A recognition program stimulated facilities to conduct timelier and higher-quality root-cause analyses of reported safety events to identify stronger actions for preventing their recurrence. Other initiatives have reduced rates of health care -- associated infections, patient mortality, and post-operative complications. Success factors include leadership accountability for performance and organizational support for testing, expanding, and adopting improvements

Climate change vulnerability and adaptation assessment for Fiji

All nations, including Fiji, that are signatories to the United Nations Framework Convention on Climate Change(UNFCCC) are obliged to provide National Communications to the Conference of Parties (COP) of the UNFCCC. The COP4 stressed the need for parties to the Convention to take into account the need for establishing implementation strategies for adaptation to climate and sea-level changes. As such, Fiji is required to submit a National Communication document that shall include information on climate change vulnerability and adaptation implementation policies and strategies. The methodology used in this assessment is based on the Intergovernmental Panel on Climate Change (IPCC) technical guidelines (Carter et al, 1994) for assessing climate change impacts and adaptation. Firstly, the present conditions are examined and key sectors identified. Then, future climatic and non-climatic scenarios are used to examine the possible effects of climate and sea-level changes on the various sectors identified. These then form the basis for identifying possible adaptation response measures for endorsement, adoption and implementation by the Fiji government. Because of the many gaps in present knowledge, and the fact that this study is focussed only on Viti Levu, the recommendations in this report should be seen as starting point for an on-going process of vulnerability and adaptation assessment in Fij

Communities Engaged in Resisting Violence

"Communities Engaged in Resisting Violence" documents a new movement in Chicago that seeks to end violence against women through community engagement and accountability, rather than solely social services and criminal justice. This report documents the innovative approaches, structures and strategies of sixteen community-based initiatives from across Chicago that are changing the way that we deal with violence against women in this society.Why do we need new approaches? The women's movement against violence has accomplished much over the past 35 years. There are now many local, regional and national organizations that provide support, advocacy, and educational resources. And yet, violence remains an omni-present fact of our day-to-day lives. The report looks at 6 limitations of the mainstream anti-violence movement:- One size fits all model, with standardized definitions, options and strategies- Over-reliance on the criminal legal system- Reliance on state funding- Exclusive focus on interpersonal violence- Exclusive focus on individual intervention- Professionalization of antiviolence workThe report then examines groups, approaches, structures and strategies, providing concrete suggestions of how individuals and communities can take action to end violence against women and girls.How anti-violence groups develop their approach: The report examines how groups have broadened the definition of violence; rethought the roles of survivors and perpetrators of violence; and identified systems of oppression as root causes of violence.How anti-violence groups structure their projects: Rather than copy the structures of the mainstream nonprofit system, groups are creating new structures and negotiating the older ones. The report looks at how groups ground their work in communities; how they grapple with the non-profit industrial complex; and how they build safe communities within the movement, including responses to acts of violence within the social justice community. Strategies to end violence: The report examines six strategies to end violence against women and girls: community engagement; community organizing; arts and performance; popular education; harm reduction and partnering with men

Dynamic inter-relationship between trade, economic growth and tourism in Malaysia

This study aims to test a hypothesis that postulate a positive inter-relationship between international flows of tourist, trade and economic growth. Although tourism is one of the major components in the trade of services, and it has been certified by large number of literatures on the strong correlation between tourism industry and economic development, yet not much is known on the dynamic inter-relationship between these three variables. Closing-up this gaping hole, this study employs the cointegration tests under autoregressive distributed lag (ARDL) structure to investigate a dynamic inter-relationship between economic development, total trade (import and export) and number of tourist arrival for Malaysia and her major tourism partners ((ASEAN countries) . The estimated result based on the long run time series behavior for number of tourist arrival, volume of total trade and economic development’s indicator shows that these three variables are moved in tandem. Interestingly, in the analysis of short run behavior, we find that number of tourist arrival has significantly Granger caused total trade flows at least for some countries. At the same time, in the short-run, we find that both growth in total trade (export and import) and international tourists’ arrival to Malaysia have uni-directionally Granger caused real income growth and there is statistical evidence for international trade to lead tourist arrival.economic growth, trade, tourism, cointegration, and Malaysia