https://padlet.com/postgraduate_futures/47bq8c0562t0weef en-us 2021-03-29 04:58:18 UTC 2022-02-12 23:23:07 UTC hello@padlet.com postgraduate_futures https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1362813710 Click the + icon to add your post. ]]> 2021-03-29 04:58:32 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1362813710 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1579214480 - The interruptions during procedures
- No hand washing before putting on gloves, then going on to handle needles
- Not documenting information, then being asked to document later
- Not changing PPE or gloves or hand washing between patients
- The 'blame' culture of the manager
- Not allowing staff to clean up between patients and bringing the next patient in when there is potential blood exposure from another patient

]]> 2021-06-02 11:47:52 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1579214480 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1587277936 Discussing incidents in public/in front of patients, 5 moments of hand hygiene not completed, no changing of PPE between patients, people in senior positions not advocating to follow correct procedure, colleagues did not offer support, time pressures from leadership and patients.

]]> 2021-06-05 20:49:45 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1587277936 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1588244226 - multiple distractions 
-not changing gloves/PPE between patients and the absence of hand hygiene 
- reprimanding staff in front of patients 
- managers attitude towards cleaning clinical workspace between patients ]]> 2021-06-06 19:07:55 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1588244226 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1589504773 Blame culture
no support from the supervisors.
Incompetent leader who states that it does not have to be perfect.
No privacy
No team work
Excessive work load]]> 2021-06-07 09:30:45 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1589504773 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1589551613 Constant interruptions whilst the nurse was trying to complete tasks.
Failure to comply with basic infection control practices ie , hand rub before putting on gloves, not changing gloves between patients
No support from upper management in regards to cleaning up spills and making the area safe for the next patient.  
Strong focus on the financial implications with running late eg overtime cost and no consideration of the potential costs that can occur is an error happens. 
No team work.

]]> 2021-06-07 10:06:10 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1589551613 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1589596972 There were distractions and non-compliance to simple hand hygiene practice which increases the probability of cross infection/contamination. There was also no concept of team work and superiors were not concerned about sanitation and after care, instead their main concern was income/profit.]]> 2021-06-07 10:42:09 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1589596972 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1589825374 -no good support from team members and managers- blame culture 
-constant interruptions during procedures
- the managers talk to the nurse in front of patients which showed no respect to the nurses, result poor performance of the nurse, as he feels he’s been let down 
- infection control- the unit manager did not care about the policy and procedures during blood spill but he hurried the nurse to get the next patient in 

]]> 2021-06-07 12:54:50 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1589825374 viviennepspeirs https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1591106125 Lack of hand washing/disinfecting between patients and equipment; 
Low infection control expectations;
Interruptions and inappropriate handover that should have already been covered; 
Pressure to work over-time and no consideration given to the nurse who may have  plans and would need a rest; 
Criticism, causing self-doubt and mental distraction;  
Disrespect for patients and their need to be important and cared for--they would have heard these interactions; 
No confidentiality--everything spoken in front of others; 
Pressure to get the next patient onto the dialysis machine without following protocol, so time pressures. 
A feeling of voicelessness and unappreciated; no offer of help to get the patient list moving, just an expression of sympathy with no generosity from the second nurse; 
No one alerted when the alarm was ringing on the second dialysis machine.  ]]> 2021-06-07 21:01:50 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1591106125 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1591282817 Firstly the interruptions from staff, and the pressure from the patient and the wife. Pressure placed on clinician from senior staff and Dr's.
Poor hand hygiene and infection control. Staff not supporting other staff after witnessing pressure/inappropriate conversations. Feeling of pressure (risk of harm).]]> 2021-06-07 23:25:15 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1591282817 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1594855858 Infection control! There was no proper hand hygiene, no changing of PPE between patients, and inappropriate cleaning of blood spill 

Too many distractions, people should not be interrupting while with a patient unless it is an emergency 

Lack of respect between staff, the manager is clearly disregarding patient safety and talking down to the staff member who is trying to do the right thing 

Speaking down to staff members in front of patients, this is highly inappropriate ]]> 2021-06-09 04:47:19 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1594855858 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1595490548 -Constant interruptions during procedure.
-Poor hand hygiene and using the same gloves om multiple patients.
-lack of respect from managers and disregard for patients' safety from managers, prioritising KPIs
 over safety.]]> 2021-06-09 11:46:01 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1595490548 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1597020323 2021-06-09 23:03:01 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1597020323 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1597938236 2021-06-10 07:15:08 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1597938236 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1598224596 -Hand hygiene - did not observe the 5 moments of hand hygiene at all.
-Senior nurse interrupted beginning of procedure with an issue that could have waited - interruptions cause stress and can bring about mistakes.
-Did not adequately address the patient concerns about the line that had been "playing up all day". The issue was not escalated to someone who may have had the time to rouble shoot.
-Nurse pressured by senior management to rush through patient not allowing him to safely decontaminate the area


]]> 2021-06-10 10:35:07 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1598224596 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1602475634 - Lack of correct hand washing practises (multiple)
- Poor management culture - interrupting staff /pt interactions; poor advice in conflict with safety
- Incorrect clinical practise with swapping lines (aside form Inf Control)
- Poor culture - staff not willing to challenge workarounds; staff not supporting colleagues with increased workloads
- Error (decision making) with asking pt to hold cannulation puncture site (assuming it caused unnecessary blood spill)]]> 2021-06-12 12:46:30 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1602475634 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1603364549 A lot of safety issues are on this video. First is there is an issue with patient safety wherein a lot of workarounds and violations are observed. No handwashing ,using of the same gloves from one patient to another.This is a breach of infection control policy. The nurse is clearly used to practising workarounds and has disregarded protocols in haemodialysis re: bloodspills, swapping lines etc. He underestimate the importance of documentation ( the kind of intervention he used with another patient who has a problem with blood pressure). The manager has no respect and compassion for his staff as well. He should be the one to monitor and assess the competency of his staff. But what he did is put productivity over safety . ]]> 2021-06-13 13:27:49 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1603364549 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1603761109 2021-06-13 22:57:55 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1603761109 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1603766247 No five moments of hand hygiene at any stage, with the patient or between patients. Staff being interrupted during procedure, understaffing, unrealistic time constraints. Ordered to ignore proper safety protocol in relation to blood spill. No assistance offered from other colleague even though she could see that he was under undue pressure. ]]> 2021-06-13 23:05:42 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1603766247 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1603917641 Interruptions, no hand washing, no team work, no compassion shown. Very uncomfortable condescending atmosphere and approach shown by manger. The lack of connection would lead to a stressful atmosphere. When people are worried and stressed they make more mistakes.]]> 2021-06-14 01:07:32 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1603917641 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1615286379 2021-06-19 06:30:35 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/1615286379 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2019655064 - pressure to complete treatment on time by family. Nurse was ready to commence treatment with Mr Martin.
- didnt actually check patient details
- interruptions by other staff. The nurse was spoken to about documentation, leading to second guessing his work. Extra work in amending documentation
- short staffed-> pressures to not fall behind
- nurse started cannulated Mr Martin and was interrupted with another patients alarm going off. 
- pressures from medical staff in regards to timing
- Blood spill after Mr Martin left, the nurse is trying to follow the correct procedures to clean up safely, but has pressures from Medical staff to keep on time.
- other nursing staff over heard conversation but did not offer help to clean or with the patients.
- Sean has not had a break -> leads to fatigue and errors.

]]> 2022-01-30 05:41:04 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2019655064 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2031097788 hand hygiene between patients 
interruptions for non urgent concerns
time pressure
poor IPC practice endorsed by management
financial concern more important than patient care]]> 2022-02-06 03:23:09 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2031097788 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2031913157 Unacceptable disposal of clinical waste, clean up, no change of PPE between tasks, other staff interrupting and not offering to assist, blame culture from management and wrong priority of getting numbers through and not patient safety and care.]]> 2022-02-06 23:02:01 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2031913157 LeanneBoonstoppel https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2033652916 Busy environment with multiple distractions and competing demands.
Culture of blaming and shaming one person, limited team work or support for each other.
Focus on time and schedules and the impact on budget, rather than patient safety, that also impacts budgets.]]> 2022-02-07 17:29:13 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2033652916 thanhbinhnguyen https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2037864270 - Unsafe practices (not sterilize hand, gloves, sterilized patients skin, change gloves/ PPE ...) .
- Manager blamed the staff without suggesting any help.
- No one knows what to do to help the staff clean the blood. 
- Many distractions while the staff was doing his job. 

]]> 2022-02-09 13:28:19 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2037864270 erickahargreaves https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2041372051 - in charge nurse not choosing appropriate time to provide feedback 
- interrupting healthcare with sharps involved
- hand hygiene moments missed 
- arm not cleansed 
- task focused instead of safety focused
- no support from upper management or other staff
- failure of changing PPE 
- money focused

]]> 2022-02-11 00:01:21 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2041372051 https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2043499570 - There were too many unnecessary interruptions that contribute to staff more prone to errors
- Supervisors/managers themselves were interrupting staff mid-procedure and instead of ensuring safety standards were followed, were the ones giving instructions that will compromise safety]]> 2022-02-12 07:09:14 UTC https://padlet.com/postgraduate_futures/47bq8c0562t0weef/wish/2043499570