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E-grāmata: Implementing Patient Safety: Addressing Culture, Conditions and Values to Help People Work Safely

(Sign Up to Safety Campaign c/o the NHS Litigation Authority, London, United Kingdom)
  • Formāts: 256 pages
  • Izdošanas datums: 11-Sep-2019
  • Izdevniecība: Productivity Press
  • Valoda: eng
  • ISBN-13: 9781351235372
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  • Formāts: 256 pages
  • Izdošanas datums: 11-Sep-2019
  • Izdevniecība: Productivity Press
  • Valoda: eng
  • ISBN-13: 9781351235372
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Over the last two decades across the globe we have seen a multitude of programs, projects and books to help improve the safety of patient care in healthcare. However, the full potential of these has not yet been reached.

Most of the current approaches are top down, programmatic and target driven. These look at problems in isolation one harm at a time with simplistic solutions that fail to support a holistic, systematic approach. They are focused on collecting incident data and learning from failure using tools that are not fit for purpose in a complex nonlinear system. Very rarely do the solutions help build the conditions, cultures and behaviours that support a safer system and help the people involved work safely.

Healthcare is stuck in a relentlessly negative approach to safety. Those working in patient safety and healthcare are struggling, and books on patient safety to date instruct the reader to continue doing the same things we have been doing for the last 20 years.

This book uniquely combines the latest thinking in safety, including creating a balanced approach to learning from what works as a way to understand why it fails, together with the evidence on building a just culture, positive workplaces and working relationships that we now know are so important for safety. It helps people understand how to address issues despite their complexities and improve safety with practical ways to truly understand what day to day healthcare work is actually like, rather than what people imagine it is like.

This book builds on the authors first book Rethinking Patient Safety which exposed what we need to do differently to truly transform our approach to patient safety. It updates the reader further on the concepts explored in the first book but also vitally helps readers understand the how.

Implementing Patient Safety goes beyond the rhetoric and provides the reader with ideas and examples for how the latest thinking can actually be achieved. It is based on the authors personal experience of leading a national culture change campaign in the National Health Service for five years. The lessons arise from helping hundreds of organisations and people rethink and implement a whole new way of thinking about improving patient safety in healthcare.
Preface xv
Acknowledgements xix
Author xxi
1 Create a Balanced Approach to Safety
1(58)
1.1 Part One Introduction
2(1)
1.2 Failure
2(9)
1.2.1 Negativity
2(2)
1.2.2 Studies of Failure
4(1)
1.2.3 Retrospective Case Note Reviews
5(3)
1.2.4 Limitations in Measuring Safety
8(3)
1.3 Safety Myths
11(13)
1.3.1 10% of Patients in Healthcare Are Harmed
12(1)
1.3.2 Incident Reporting Systems will Capture all the Things that Go Wrong
13(1)
1.3.3 Incident Reports Can Be Used to Prioritise Solutions and Activity
13(1)
1.3.4 Incident Reports and Investigations Provide Unambiguous Data (the Truth)
14(2)
1.3.5 We Should Aim for a Rise in Incident Reports Because It Demonstrates a Good Safety Culture
16(2)
1.3.6 A Reduction in Incident Reports Means We Are Learning
18(1)
1.3.7 Incident Investigations and Root Cause Analysis Will Identify the Causes of What Happened
19(3)
1.3.8 Linear Cause and Effect Models Will Work in Healthcare
22(1)
1.3.9 We Simply Need to Learn from Aviation (Or Other High Risk Industries)
23(1)
1.4 Concepts and Theories
24(1)
1.5 The Three Models of Safety
25(4)
1.5.1 Summary of the Three Models of Safety
26(1)
1.5.2 The Three Models in Relation to Healthcare
26(3)
1.6 Complex Adaptive Systems
29(14)
1.6.1 Complexity Science
29(1)
1.6.2 Simple, Complicated and Complex
30(3)
1.6.3 Healthcare
33(3)
1.6.4 Complexity and Dilemmas
36(1)
1.6.4.1 A Local Dilemma
37(2)
1.6.4.2 A Global Dilemma
39(2)
1.6.4.3 Let's Talk about It
41(2)
1.7 Safety I and Safety II
43(10)
1.7.1 The Prevailing Approach to Safety
43(2)
1.7.2 Erik Hollnagel and Resilience Engineering
45(2)
1.7.3 A Different View
47(2)
1.7.4 `Safety F and Safety IF
49(1)
1.7.5 How Do We Do It?
50(3)
1.8 Part One Summary
53(3)
1.9 Part One Actions
56(3)
2 Turn the Theory into Practice
59(56)
2.1 Part Two Introduction
60(1)
2.2 Implementation
60(6)
2.2.1 What Is Implementation?
60(2)
2.2.2 Implementation and Healthcare
62(2)
2.2.3 What Can We Do Differently?
64(2)
2.3 Narrow the Gap between Work-as-imagined and Work-as-Done
66(8)
2.3.1 Work-as-Done
67(1)
2.3.2 Work-as-Imagined
67(1)
2.3.3 Work-as-Prescribed
68(2)
2.3.4 Work-as-Disclosed
70(2)
2.3.5 The Problems with Inspection
72(1)
2.3.6 Why Is It Important to Narrow the Gap?
73(1)
2.4 Models to Understand Work-as-Done
74(10)
2.4.1 Ethnography and Simulation
75(1)
2.4.2 Positive Deviance
76(4)
2.4.3 Exnovation
80(3)
2.4.4 Golden Days and Lives Saved
83(1)
2.5 Functional Resonance Analysis Method
84(12)
2.5.1 What Is the Functional Resonance Analysis Method or FRAM?
84(2)
2.5.2 Terminology
86(4)
2.5.3 The Four Steps
90(2)
2.5.4 The Four Principles
92(2)
2.5.5 Examples of Questions
94(1)
2.5.6 FRAM and Safety
95(1)
2.6 Measurement and Monitoring Framework
96(5)
2.6.1 The Five Dimensions
99(1)
2.6.2 The Five Questions
100(1)
2.7 Change the Language to Change the Mindset
101(8)
2.7.1 Patient Safety
104(1)
2.7.2 Human Error
104(2)
2.7.3 Honest Mistake
106(1)
2.7.4 Violations
106(2)
2.7.5 Zero Harm
108(1)
2.7.6 Never Events
109(1)
2.8 Part Two Summary
109(2)
2.9 Part Two Actions
111(4)
3 Urgently Tackle the Culture of Blame
115(36)
3.1 Part Three Introduction
116(1)
3.2 Culture
117(2)
3.2.1 Healthcare Culture
118(1)
3.2.2 Safety Culture
118(1)
3.3 Blame, Shame and Fear
119(9)
3.3.1 Blame
119(3)
3.3.2 Shame
122(1)
3.3.3 Fear
123(2)
3.3.4 Impact on Staff
125(3)
3.4 Incivility and Bullying
128(6)
3.4.1 Incivility
128(2)
3.4.2 Impact of Incivility
130(1)
3.4.3 Bullying
131(2)
3.4.4 What Can We Do?
133(1)
3.5 Just Culture
134(12)
3.5.1 Just Culture
135(4)
3.5.2 Clinical Negligence
139(1)
3.5.3 Accountability and Responsibility
140(1)
3.5.4 Who Gets to Draw the Line?
141(1)
3.5.5 Restorative Just Culture
142(1)
3.5.6 Who Was Hurt?
143(1)
3.5.7 What Do They Need?
143(1)
3.5.8 Whose Obligation Is It to Meet the Need?
144(1)
3.5.9 Mersey Care Partnership
144(2)
3.6 Part Three Summary
146(1)
3.7 Part Three Actions
147(4)
4 Care for the People that Care
151(52)
4.1 Part Four Introduction
152(2)
4.2 Positivity and Joy
154(9)
4.2.1 Positive Emotions
154(1)
4.2.2 Positive Stories
155(1)
4.2.3 Joy
156(6)
4.2.4 Positivity, Joy and Safety
162(1)
4.3 Kindness and Empathy
163(9)
4.3.1 Kindness
163(2)
4.3.2 Lack of Kindness
165(1)
4.3.3 What Can We Do Differently?
166(1)
4.3.4 Compassion
167(1)
4.3.5 Empathy
168(1)
4.3.6 Listening
169(2)
4.3.7 Kindness, Empathy and Safety
171(1)
4.4 Appreciation and Gratitude
172(5)
4.4.1 Appreciation
173(1)
4.4.2 Gratitude
173(1)
4.4.3 Appreciation and Gratitude
174(2)
4.4.4 Appreciation, Gratitude and Safety
176(1)
4.5 Learning from Excellence
177(4)
4.5.1 What Is Learning from Excellence?
177(1)
4.5.2 Positive Feedback
178(1)
4.5.3 The Learning Part of Learning from Excellence
179(1)
4.5.4 Other Appreciation Programmes
180(1)
4.5.5 Learning from Excellence and Safety
180(1)
4.6 Wellbeing
181(16)
4.6.1 What Do We Mean by Wellbeing?
182(1)
4.6.2 Why Is It Important?
182(2)
4.6.3 Hunger
184(1)
4.6.4 Fatigue
185(4)
4.6.5 Relationsh ips
189(2)
4.6.6 Psychological Safety
191(2)
4.6.7 Loneliness and Isolation
193(3)
4.6.8 Wellbeing and the Impact on Safety
196(1)
4.7 Part Four Summary
197(2)
4.8 Part Four Actions
199(4)
5 Plant Trees You Will Never See
203(14)
5.1 Legacy
203(4)
5.2 A Call for a Movement
207(5)
5.2.1 Why Am I Talking about Social Movements?
207(2)
5.2.1.1 Why a Social Movement for Safety?
209(2)
5.2.1.2 What Can You Do?
211(1)
5.3 Conclusion
212(5)
References 217(10)
Index 227
Dr Suzette Woodward works in the English National Health Service (NHS). She is an internationally renowned expert in patient safety and has been studying safety in healthcare settings since the 1990s. Her particular areas of interest include implementation of patient safety and the translation of theory and public policy into practice. She has an exceptional ability to take complex issues and make them easy to understand as well as being able to weave together different threads in a unique and stimulating way.

Suzette is a trained general and paediatric nurse who specialised in paediatric intensive care nursing for over ten years. She has a Masters in Clinical Risk and a Doctorate in Patient Safety and was the recipient of the Ken Goulding Prize for Professional Excellence in 2008. Her research focused on implementation of national patient safety guidance. She is also a visiting professor for Imperial College University in London. Suzette was awarded the Daisy Ayris Medal for services to perioperative nursing in 2011, named one of the top 50 inspirational women in the NHS in 2013, one of the top 50 nurse leaders in the NHS in 2014 and one of the top clinical leaders in the NHS in 2014.

Her first book, Rethinking Patient Safety, and the accompanying blogs have helped shape the conversation on thinking differently about safety in healthcare and she is a sought-after speaker at international and national conferences, workshops, symposia and meetings, having delivered over 200 keynote addresses on patient safety.