Resources

Clinical deterioration is a key risk for any organisation providing clinical care. This qualitative study investigates how three organisational influences - leadership, culture and hierarchies -  impact healthcare professionals' readiness to raise concerns about patient deterioration. 

The role of healthcare leaders is becoming increasingly complex and carries significant responsibility for consumer and employee safety. Leaders and managers often experience tension between adhering to regulatory standards and addressing the unique needs of their consumers and staff.  This dual focus can lead to a fragmented effort, where Health, Safety and Environment (HSE), with a focus on workers, and Quality and Patient Safety (QPS), with a focus on consumers, operate in silos rather than as integrated components of a cohesive safety strategy.
 

The Commission has released two new resources summarising the evidence on the effectiveness of interventions that aim to improve medication management at transitions of care.

The Victorian Safety Culture Guide (VSCG), from Safer Care Victoria, supports healthcare leaders to measure and monitor their organisation’s safety culture;  and is also a useful tool for other sectors to adapt and apply to develop their safety cultures. 

‘Safety culture is like a garden: to bloom, it must be planned, planted and  tended.’ This is a key message from a systematic review of safety culture and an excellent reminder that culture is never ‘set and forget’.

Correct identification of patients has been recognised as a critical safety issue for many years. A recent report from the UK’s Health Services Safety Investigation Body (HSSIB), compiles evidence from various investigations and sources to explore the factors contributing to patient misidentification in healthcare. The report defines 'positive patient identification' as the accurate identification of a patient to ensure they receive the correct care. Whereas, 'patient misidentification' occurs when a patient is wrongly identified as someone else, leading to potential harm from incorrect or missed treatment.

We spend a lot of time on root cause analysis (RCA) – and have done it for 20 years or so. But key clinical risks remain stubbornly consistent.

We frequently discuss the importance of a ‘safety culture’ in human services – but what are the key ingredients? This scoping review synthesises evidence from multiple studies to identify key factors contributing to patient safety culture. Although the review focused on hospitals, the findings are relevant for all human service leaders seeking to build or strengthen their culture of safety.

Clinical Guidelines are developed to standardise practice and provide a solid evidence base for care. They are essential components of clinical governance to support safe and effective care and serve as valuable tools for training.  

As this study reveals, guidelines can also be a source of confusion and misapplication. Ambiguities in guidelines can result in varying interpretations among healthcare providers, contributing to inconsistent care and potential patient harm. 

The inter-dependency of clinician wellbeing and patient safety is well accepted. Staff burnout is a widespread problem and patient safety improvement appears to have stalled. This survey of 2187 physicians and 6643 nurses practising in 64 hospitals in six European countries investigated the well-being of physicians and nurses in hospital practice in Europe, and identified interventions that hold promise for reducing adverse clinician outcomes and improving patient safety.