Resources

Listening to patient voices has many benefits and is proven to contribute to care and service improvement. This article describes how consumers can help healthcare organisations detect and address performance drift, described as gradual deviations from best practice that become normalised over time.  

The importance of a safety culture, incorporating psychological safety and encouraging people to speak up, has been identified as critical to safe care for some time. However, achieving and maintaining such an environment can be challenging. This metasynthesis examines 15 studies to “review and synthesise qualitative research on nurses' experiences of speaking up”. 

We know that AI poses risks and also has potential for significant benefits.  In January 2024, the Institute for Healthcare Improvement Lucian Leape Institute convened an expert panel to review the literature and explore these benefits and risks as they relate to consumer safety, focusing what they considered to be key uses for genAI in health care: documentation support, clinical decision support, and consumer-facing chatbots. 

In today’s rapidly evolving healthcare landscape, technology is both an enabler and a challenge, reshaping how we deliver, manage, and access healthcare services. Liz will discuss the critical role of clinical governance and safety in digital health. As we explore frameworks that underpin sound governance, including some takeaways from the Health Innovation Community (HIC) conference, we’ll consider what it means to 'think differently' about health technology - why the integration of clinical governance isn't just about compliance but about achieving better, safer patient outcomes. 

Root Cause Analysis (RCA) is a valuable tool in healthcare for identifying systemic factors that contribute to errors. However, its traditional deterministic approach often focuses on finding a single root cause, typically human error, which can limit its effectiveness in preventing future adverse events. This narrow focus is compounded by hindsight bias, where the outcome influences how past decisions and actions are judged. As a result, conventional RCA can inadvertently damage organisational culture by attributing blame instead of addressing system-level issues.

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 Global Patient Safety Report 2024 by the World Health Organisation (WHO) highlights the critical global issue of patient safety, recognising it as a key component of quality healthcare that still requires significant evolution. The report's main goals are to raise awareness of patient safety risks, provide insights into the scope of the problem and set the stage for global initiatives to reduce harm to patients in healthcare settings.  

Medication errors remain a stubbornly challenging issue in the provision of safe care. Although we often associate inpatient settings with medication issues, this comprehensive review studied the triumvirate of prescribing, dispensing and administration to determine common causal factors of mistakes and inaccuracies, leading to incidents in ambulatory and outpatient settings.

Outpatient safety receives a different level of discussion and focus than inpatient safety. We may not consider that outpatients can experience harm in the same way that inpatients can, which could reduce the focus on collecting accurate outpatient incident data. But even outpatient care can cause life-threatening harm, as this study shows.

What skills and experience do clinical governance or similar teams and units need to support your organisation's safety and quality agenda? In this webinar, Dr Sarah Fischer, Acting Executive Director of Safety at Safer Care Victoria, discussed the various roles and relationships to ensure fit-for-purpose teams.