Building an Organisation with a Memory on Just Culture? Part Two
Sixteen years after an Organisation with a Memory was published, Jonathan Hazan Director at Datix considers how people and processes are at the heart of a Just Culture in healthcare. Reflecting on the...
View ArticleThe Leadership Report Card – How well am I doing?
Download this Article For a good part of my career, I was a front-line stakeholder, providing healthcare to patients and collaborating with them to achieve best outcomes. So in this sense, I was a...
View ArticleWhy every Datix is a GREATix
Here at the Datix HQ in Wimbledon, we’ve been learning about and discussing recent initiatives to report and learn from ‘excellence incidents’. There are a number of compelling reasons why reporting...
View ArticleFlorence Nightingale – “Authentic Leadership” for Patient Safety
Download this Article War is a terrible, horrible thing. As a former military physician, I have been to war and have seen the mayhem inflicted by the mechanics and methodologies of modern warfare,...
View ArticleFrom ‘no blame’ to a ‘just culture’
Last month, the Parliamentary and Health Service Ombudsman (PHSO) published a report relating to the tragic death of 3 year old Sam Morrish. Sam died in 2010 from sepsis. In 2014, the PHSO published a...
View ArticleWhy has root cause analysis not led to broad-based improvements in patient...
As its name would suggest, root cause analysis is the process by which teams of individuals assess and identify the underlying issues and factors that lead to unintended outcomes. In theory, root cause...
View Article“Lessons have been learned”
Whenever there is a story in the news about a serious NHS failure involving avoidable harm or death, the phrase ‘lessons have been learned’ is invariably included as part of the organisation’s media...
View ArticleWhy rigorous investigations matter
Advancements made in the healthcare industry over the years have been truly crucial in how we value and regard medicine. Technologies have been developed to perform surgeries and procedures not thought...
View ArticleMobile apps in healthcare
We live in an era of mobile technology. Everything we need to know, everything we want to purchase or browse or better understand is carried with us in our pockets. Whether bank account summaries,...
View ArticleTraining + Mentoring + Personality = Leadership
Download this Article Are healthcare leaders born with the capacity to lead or a can anyone be trained to lead? It’s the old nature versus nurture debate, and the scientific underpinnings suggest that...
View ArticleHow Big Data is improving healthcare
It’s easy to take data for granted. For many of us, data seems to simply materialize for our benefit. The methods by which data is collected is invisible to nearly all, save the individuals responsible...
View ArticleHow organizations can learn from incident reporting
In cases of incident reporting, it’s easy to focus on mistakes and events that directly result in the harm or improper care of individuals. However, incidents often include factors such as minor...
View ArticleWhat is a Just Culture?
To establish a just culture within the workplace is to foster a standard of accountability and trust that values learning over accusations. As businesses are comprised of humans, and humans are...
View ArticleImproving Incident Investigations – Where there is a need, there must be a way!
There is an urgent need in health care that must be confronted. The latest studies regarding the deaths related to health care reveal that about 250,000 people die in the USA every year due to...
View ArticleWhy Culture Matters – Supporting Quality Investigations for Learning
The environment in which healthcare services are provided is complex. This is confounded by numerous variables that impair the noble goals of achieving higher reliability and improving patient and...
View ArticleHow Do Human Factors Effect Decision Making in Healthcare?
Try as we might – despite our greatest efforts and accomplishments – humans have yet to create the perfect technology, one which subsists independently of human support and influence. We have developed...
View ArticleDiagnostic Delays and Errors – Elephants in the Room
Diagnostic errors are ipso facto delays in arriving at an accurate diagnosis, often resulting in delays in appropriate therapeutic interventions and possibly resulting in harm. The reasons for...
View ArticleLearning from Avoidable Harm and Death in Healthcare
In recent years, there has been an increasing recognition that the way in which the NHS investigates and learns from instances of avoidable harm and death is extremely variable and often poor. This is...
View ArticleCan a Plan, Do, Study, Act (PDSA) Approach Work for Patient Safety Incidents?
Incidents in patient safety typically arise amidst several possible contributing factors and, without appropriate problem-solving strategies, can be exceedingly difficult to assess. Using process...
View ArticleWhat Barriers Exist to Quality Improvement in Healthcare?
The healthcare industry is boundless, encompassing a seemingly infinite network of organizations and individuals through a series of hospitals, doctors’ offices, specialists, manufacturers, and various...
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