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 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. 

We know the critical role that healthcare governing boards play in driving improvements in care quality and safety.  Cultivating board understanding and focus can be challenging, however.  We are still a long way from all boards having the same comfort with clinical governance as they do with corporate governance. This article suggests four key actions to support boards to enact their responsibilities for care quality.

‘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’.

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.

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.

Variation in healthcare quality is an ongoing issue. This study seeks to understand how differences in hospital practices and policies can lead to disparities in consumer outcomes and overall care quality. The authors compared process and outcome measures to detect variation and characteristics of hospitals with lower variation.

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.