Resources

A cause and effect diagram, also known as an Ishikawa or fishbone diagram, is a visual tool used to explore the potential causes of a problem. First developed by Kaoru Ishikawa in 1943 at Kawasaki Steel Works, these diagrams help teams systematically sort and relate factors that may contribute to an issue.

Artificial intelligence (AI) is rapidly reshaping the nursing profession, offering promising advancements across education, clinical care, and operational management. A recent integrative review of 25 studies highlights how AI is being integrated into nursing practice, revealing both benefits and challenges. 

A recent Swedish study has shed light on the extraordinary challenges faced by ambulance nurses during the COVID-19 pandemic, offering valuable insights into frontline decision-making, adaptation, and learning under extreme conditions. Drawing on 56 critical incidents reported by 28 registered nurses, the research identified four key themes that illustrate the complexity and ethical weight of their experiences. 

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.

In Australian health services, roles that support consumer safety are a mix of trained specialists, people who evolve on the job and those who struggle through the basics with little opportunity for development. In the UK,  the NHS has created a new role of ‘patient safety specialist’, introduced to bring a more structured, professional approach to patient safety. This evaluation article seeks to understand the professionalisation of patient safety, with implications for the further development of patient safety specialists in the UK and other countries. 

Over the past three decades, many health systems have sought to enhance care delivery. Despite various approaches such as quality improvement and lean management these efforts can fall short. Failures are often attributed to leaders and workers not doing the right things. This article argues that the real quality problems lie in the underlying systems staff work with. It says that human service organisations will be more successful if they focus on designing systems that support the delivery of high-quality care, rather than trying to fix the people working within them.

Spreading, scaling up, and sustaining improvements in human services is a complex challenge that many countries, including the UK, USA, and Australia, have been tackling. Despite significant efforts, the sustainability of scaling up local improvements remains low. One reason for this is the traditional, linear approach to spreading improvements, which often overlooks the complexity and evolving nature of healthcare systems.

It has been reported that complaints relating to registered health practitioners increased over the 2021/2022 financial year. Further (and separately), in aged care, there was a total of 2,767 complaints made in the first quarter of 2022 and 2,642 complaints in the second quarter. Both these figures had also trended upwards compared with the corresponding numbers in 2021 (with 2,313 in the first quarter of 2021 and 2,261 in the second quarter).

Continuous improvement is the essence of clinical governance. But continuous improvement requires change, and change can be confronting. As we predictably move towards a more digitised world - including in healthcare, and aged care – change is also inevitable.

What does safety II really mean in practice? How can your organisation develop high performing safety II teams?