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Learning from excellence in critical care
The document discusses the transition from traditional safety practices to a more holistic understanding of safety, emphasizing the importance of recognizing positive practices and innovations in healthcare. It highlights examples of proactive communication and teamwork in patient care, illustrating how supportive and compassionate actions enhance safety and quality. Additionally, the document notes the value of recognizing contributions through simple affirmations like 'well done' as a key quality improvement intervention.
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Learning from excellence in critical care
- 1. Learning from Excellence AdrianPlunkett, Birmingham UK SMACC June 16th 2016 @adrianplunkett
- 3. Source: Eurocontrol. From Safety1 to Safety 2. A white paper www.eurocontrol.int
- 4. Trying to understandsafety by only looking at incidents is like trying to understand sharks by only looking at shark attacks Attributed to Bob Wears
- 5. Theirs nothing worsethan misplaced apostropheโs
- 6. 1 + 1= 2 2 + 2 = 4 3 + 3 = 7 4 + 4 = 8 5 + 5 = 10
- 7. Rieger at en.wikipediaderivative work: JohnKiat (talk) derivative work: JohnKiat [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0/) or GFDL], via Wikimedia Commons
- 11. Negativity culture: Adverse events Error Risk IR1/ Datix SIRI / SUI Never event
- 12. Second victim effect Thirdvictim? Fourth victim?
- 13. Source: Eurocontrol. From Safety1 to Safety 2. A white paper www.eurocontrol.int
- 17. What do peoplereport? No one has reported themselves Reports focus on what was DONE Often โmotivational > informationalโ Many themes
- 18. โฆ took herown initiative to design a bespoke care plan on ventilation weaning on a patient with complex needs that is clear for both her colleagues and parents to understand. This meant that everyone involved in this patient's care had a shared mental model
- 19. โGreat innovation andorganisation of the ward-round with a new structure trialled that was more efficient and more enjoyable for the teamโ
- 20. โ...during a busyshift ... took the time to communicate with family ... compassion and kindness... the family was comforted and reassured... Empathy, kindness, extremely supportive towards the whole family.โ
- 21. โ...was looking aftera patient on PICU. During the morning ward round not only had he spotted a ten fold drug dose error which he flagged for our attention, he also challenged very appropriately and constructively about why a child with a viral infection was on antibiotics.โ
- 23.
- 24. PRIP study 0% 20% 40% 60% 80% 100% Pre Post Percentageofprescriptions Studyperiod Effect of positive reporting on prescribing practice Gold standard Not gold standard
- 26. Imagine you hadthree wishes...
- 28. โ... The twomost powerful words in the English language are โwell doneโโ Sir Alex Ferguson
- 29. โSaying โthank youโor โwell doneโ might be the simplest quality improvement intervention of allโ Dr Emma Plunkett
Editor's Notes
- #9ย Prospect theory We value loss more than gain
- #10ย Prospect theory We value loss more than gain
- #11ย Negative effects of looking at the negative pervades our wider society... See the top 10 most read What use are these? These are most read Entertainment... We are attracted to it, good at spotting. Doesnโt it help in healthcare?
- #14ย Contrary to popular belief and their widespread use in headlines, positive superlatives (i.e., โbestโ, โalwaysโ) do not appear to be compelling to readers. In fact, our data shows just the opposite. For our headline analysis, we drew a sample of approximately 65,000 paid link titles from the pool of all English language paid links that ran in Outbrainโs network between the months of April and July 2012 and measured the impact of superlative use on engagement (click-through rate). As you can see in the graph below, the results were very interesting! ย Compared with headlines that contained neither positive (โalwaysโ or โbestโ) nor negative (โneverโ or โworstโ) superlatives, headlines with positive superlatives performed 29% worse and headlines with negative superlatives performed 30% better.ย The average click-through rate on headlines with negative superlatives was a staggering 63% higherย than that of their positive counterparts. These results were replicated in a subsequent headline study that included data from the months of August โ September 2012. So why the attraction to the negative and the distaste for the positive? Audience aversion to positive superlatives may simply be a product of overuse, or it could be because readers are skeptical of sourcesโ motives for endorsement. On the flip side, sources of negative information may be more likely to be perceived as impartial and authentic. Whereas positive superlatives may have become clichรฉd through overuse, negative superlatives may be more unexpected and intriguing. Want to put these findings to the test? If youโre amplifying your content with Outbrain, try testing out some headlines with negative superlatives inย your campaign. Donโt have an Outbrain campaign? Check out ourย Amplify DIYplatform to see how you can start growing your audience!
- #16ย Trouble is it generates a negative culture: The language of negativity. IR1 story Why is this?
- #23ย Common theme.
- #24ย Innovations are difficult to capture unless you look for them Weโve captured quite a few now via IR2. Workarounds and safety-II
- #25ย Is this actionable intellgence? Just nice? Show appreciation, more likely to increase motivation. Motivational vs. Informational.
- #26ย Near miss โ positive reporting of near miss, rather than negative reporting Challenge authority gradient Used a example of communication within the unit
- #29ย Story about name and shame Positive reporting can also be used to improve quality as a driver, rather than negative targets... Good practice increases; error (or bad practice) necessarily decreases. In contrast to the usual approach to QI or safety...