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Content ArticleThis report contains the findings and recommendations of the Organization Designation Authorization (ODA) Expert Review Panel formed under Section 103 of the 2020 Aircraft Certification, Safety, and Accountability Act (ACSAA). Reporting to the US Federal Aviation Administration (FAA) and Congressional committees of jurisdiction, the Expert Panel reviewed the safety management processes and their effectiveness for each holder of an ODA for the design and production of transport aeroplanes.
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Content ArticleThis paper addresses the fundamental discipline theoretic question of whether situation awareness is a phenomenon best described by psychology, engineering or systems ergonomics. Each of these disciplines places a different emphasis on the notion of what situation awareness is and how it manifests itself. Each of the perspectives is presented and compared with reference to studies in aviation and other domains.
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Content ArticleLearning vicariously from the experiences of others at work, such as those working on different teams or projects, has long been recognised as a driver of collective performance in organisations. Yet as work becomes more ambiguous and less observable in knowledge-intensive organisations, previously identified vicarious learning strategies, including direct observation and formal knowledge transfer, become less feasible. Drawing on ethnographic observations and interviews with flight nurse crews in an air medical transport program, Chris Myers inductively build a model of how storytelling can serve as a valuable tool for vicarious learning. He explores a multistage process of triggering, telling, and transforming stories as a means by which flight nurses convert the raw experience of other crews’ patient transports into prospective knowledge and expanded repertoires of responses for potential future challenges. Further, he highlights how this storytelling process is situated within the transport programme’s broader structures and practices, which serve to enable flight nurses’ storytelling and to scale the lessons of their stories throughout the entire programme. He discusses the implications of these insights for the study of storytelling as a learning tool in organizations, as well as for revamping the field’s understanding of vicarious learning in knowledge-intensive work settings.
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Content ArticlePatients treated and transported by Helicopter Emergency Medical Services (HEMS) are prone to both flight and medical hazards, but incident reporting differs substantially between flight organisations and healthcare, and the extent of patient safety incidents is still unclear. This study in the Journal of Patient Safety is based on in-depth interviews with eight experienced Norwegian HEMS physicians from four different bases from February to July 2020. The study aimed to explore the physicians’ experience with incident reporting and their perceived areas of risk in HEMS. The authors concluded that sparse, informal and fragmented incident reporting provides a poor overview of patient safety risks in HEMS. A focus on organisational factors and system responsibility is needed to further improve patient safety in HEMS, alongside research on environmental and contextual factors.
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Content ArticleJudy Walker looks at the ways in which team learning can contribute to safety in healthcare using tools such as After Action Review (AAR). She explores research highlighted in Amy Edmondson's new book The Right Kind of Wrong that demonstrates the impact on certain safety indicators of flight crews building a team culture through working together consistently. Judy suggests that gaining insights about co-workers through proximity accelerates the process of learning for teams.
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Content ArticleThe helicopter, G-MCGY, was engaged on a Search and Rescue mission to extract a casualty near Tintagel, Cornwall and fly them to hospital for emergency treatment. The helicopter flew to Derriford Hospital (DH), Plymouth which has a Helicopter Landing Site (HLS) located in a secured area within one of its public car parks. During the approach and landing, several members of the public in the car park were subjected to high levels of downwash from the landing helicopter. One person suffered fatal injuries, and another was seriously injured. The investigation carried out by the Air Accidents Investigation Branch identified the following causal factors: The persons that suffered fatal and serious injuries were blown over by high levels of downwash from a landing helicopter when in publicly accessible locations near the DH HLS. Whilst helicopters were landing or taking off, uninvolved persons were not prevented from being present in the area around the DH HLS that was subject to high levels of downwash. Helicopters used for Search and Rescue and Helicopter Emergency Medical Services (HEMS) perform a vital role in the UK and, although the operators of these are regulated by the UK Civil Aviation Authority, the many helicopter landing sites provided by hospitals are not. It is essential that the risks associated with helicopter operations into areas accessible by members of the public are fully understood by the HLS Site Keepers, and that effective communication between all the stakeholders involved is established and maintained. Therefore, nine Safety Recommendations have been made to address these issues.
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Designing in risk: Measuring safety part 3
NMacLeod posted an article in Improving patient safety
The relationship between management and the workforce, in very simplistic terms, can be considered one of reward in return for effort. The contracted effort is communicated through a roster. In organisations that have a continuous operation, blocks of effort are distributed to maintain the flow of output. The organisation of effort, then, is a legitimate function of management. Norman's previous blog looked at performance variability under normal conditions. In this blog, Norman looks at the impact of physiological states and how management’s organisation of effort degrades decision-making.- Posted
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Content ArticleIn a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk. In part 1 of this blog series, Norman suggested that measuring safety is problematic because the inherent variability in any system is largely invisible. Unfortunately, what we call safety is largely a function of the risks arising from that variability. In this blog, Norman explores how error might offer a pointer to where we might look.
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Content Article
Can you measure safety? Part 1
NMacLeod posted an article in Improving patient safety
In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk. He argues that, to measure safety, we need to understand the creation of risk. In this first blog, Norman looks at the problems of measuring safety, using an example from aviation to illustrate his points.- Posted
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Content ArticleBowtie is a visual tool which effectively depicts risk, providing an opportunity to identify and assess the key safety barriers either in place or the ones lacking, between a safety event and an unsafe outcome. This guidance from the UK Civil Aviation Authority outlines how the bowtie model works and how to use it.
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Content ArticleThose who work in health and care are keenly aware of the need to identify and manage risks to protect patients from harm. But we are not the only industry that must take safety seriously. This video from the Healthcare Services Safety Investigation Branch (HSSIB) we compare notes with other safety-conscious industries – oil and gas, shipping, aviation, rail, road, nuclear and NASA – to understand their approach to safety management. In these fields, systems for organising and coordinating safety are often called Safety Management Systems (SMSs). See also HSSIB's report: Safety management systems: an introduction for healthcare.
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Content ArticleSafety Management Systems (SMSs) are an organised approach to managing safety which are widely used in different industries. In this report, the Health Services Safety Investigations Body (HSSIB) identifies the requirements for effective SMSs, how these are used in other safety-critical industries and considers the potential of application of this approach in healthcare. It makes safety recommendations for NHS England and the Care Quality Commission in relation to this. See also HSSIB's video Introduction to safety management systems.
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Content ArticleThis issue of Hindsight is on the theme of Just Culture…Revisited. The articles reflect Just Culture at the corporate and judicial levels from the perspectives of personal experience, professional practice, theory, research, regulation, and law. You will find a diverse set of articles from a diverse set of authors in the context of aviation, maritime, rail and healthcare. What is ‘just’? How should we conceptualise Just Culture? How should we design and implement regulations, policies and protocols relating to Just Culture? What gets in the way of Just Culture? In this issue, leading voices from the ground and air share perspectives on these questions.
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Content ArticleHealthcare often uses the experience of aviation to set its patient safety agenda, and the benefits of a ‘safety management system’ (SMS) are currently being espoused, possibly because the former chief investigator for HSIB, Keith Conradi, had an aviation background. So, what does an SMS look like and would it be beneficial in healthcare? In this blog, Norman MacLeod discusses aviation's SMS, its many component parts, the four pillars of an SMS, just culture and its role in healthcare.
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Content ArticleThis is the recording of a presentation given by Niall Downey at a recent Patient Safety Management Network (PSMN) meeting. Niall considered why error is inevitable, how it affects many different industries and areas of society and, most importantly, what we can do about it.
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Content ArticleCommercial aviation practices, including the role of the pilot monitoring, the sterile flight deck rule, and computerised checklists, have direct applicability to anaesthesia care. Checklists are commonly used in the operating room, especially the World Health Organization surgical safety checklist. However, the use of aviation-style computerised checklists offers additional benefits. In this editorial, Jelacic et al. discuss how these commercial aviation practices may be applied in the operating room.
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Content ArticleCHIRP was formed in 1982 as a result of a joint initiative between the Chief Scientific Officer Civil Aviation Authority (CAA), the Chief Medical Officer CAA and the Commandant Royal Air Force Institute of Aviation Medicine (IAM). The programme was based on the Aviation Safety Reporting System (ASRS) that had been formed in the United States of America in 1976 under the management of National Aeronautical and Space Administration (NASA).
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Content ArticleThe Aviation Safety Reporting System (ASRS) is an important part of the continuing effort by the US government, industry and individuals to maintain and improve aviation safety. The ASRS collects voluntarily submitted aviation safety incident/situation reports from pilots, controllers and others. it analyses and responds to these incident reports to reduce the likelihood of aviation accidents. ASRS data are used to: identify deficiencies and discrepancies in the National Aviation System (NAS) so that these can be remedied by appropriate authorities. support policy formulation, planning for and improvements to the NAS. strengthen the foundation of aviation human factors safety research. This is particularly important since it is generally recognised that over two-thirds of all aviation accidents and incidents have their roots in human performance errors. The ASRS website outlines the purpose and aims of the system, provides details on how to submit reports and lists related research studies and resources.
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Content ArticleIn this article in the Irish Times, Niall discusses his book, Oops! Why Things Go Wrong, and explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, and most importantly, what we can do about it. You can also listen to an interview with Niall on BBC Radio Ulster’s Talkback (Listen from 38 mins to 57 mins). Related reading on the hub: Oops! Why things go wrong – a blog by Niall Downey
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Content ArticleIt has become fashionable to purge the term ‘error’ from the safety narrative. Instead, we would rather talk about the ‘stuff that goes right’. Unfortunately, this view overlooks the fact that we depend on errors to get things right in the first place. We need to distinguish between an error as an outcome and error as feedback, writes Norman MacLeod in this blog for the hub.
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Content ArticlePoorly designed electronic health records (EHRs) are common, and research shows poor design consequences include clinician burnout, diagnostic error, and even patient harm. One of the major difficulties of EHR design is the visual display of information, which aims to present information in an easily digestible form for the user. High-risk industries like aviation, automotive, and nuclear have guidelines for visual displays based on human factors principles for optimised design. In this study, Pruitt et al. reviewed the visual display guidelines from three high-risk industries—automotive, aviation, nuclear—for their applicability to EHR design and safety.
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Content ArticleOur heavily curated Instagram society has become very intolerant of error. In an era where everything we present is airbrushed, tweaked, filtered and polished before being released into the wild, we labour under the misapprehension that the real world is similar. We are sadly mistaken. The real world is messy, imperfect and error-prone. In this blog, Niall Downey talks about his book, Oops! Why Things Go Wrong, which explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, how it is sometimes actually quite efficient from a physiological standpoint and, most importantly, what we can do about it.
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Content Article"I am thirty miles south of London’s Gatwick Airport, the world’s busiest single-runway airport, when one of the seven Flight Control computers in my Airbus A320 aircraft fails . . . ’ So begins this pioneering book by Niall Downey – a cardio-thoracic surgeon who retrained to become a commercial airline pilot – where he uses his expertise in medicine and aviation to explore the critical issue of managing human error. With further examples from business, politics, sport, technology, education and other fields, Downey makes a powerful case that by following some clear guidelines any organisation can greatly reduce the incidence and impact of making serious mistakes. While acknowledging that in our fast-paced world getting things wrong is impossible to avoid completely, Downey offers a strategy based on current best practice that can make a massive difference. He concludes with an aviation-style Safety Management System that can be hugely helpful in preventing avoidable catastrophes from occurring.
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News ArticlePeople concerned about the safety of patients often compare health care to aviation. Why, they ask, can’t hospitals learn from medical errors the way airlines learn from plane crashes? That’s the rationale behind calls to create a 'National Patient Safety Board,' an independent federal agency that would be loosely modelled after the US National Transportation Safety Board (NTSB), which is credited with increasing the safety of skies, railways, and highways by investigating why accidents occur and recommending steps to avoid future mishaps. But as worker shortages strain the US healthcare system, heightening concerns about unsafe care, one proposal to create such a board has some patient safety advocates fearing that it wouldn’t provide the transparency and accountability they believe is necessary to drive improvement. One major reason: the power of the hospital industry. The board would need permission from health care organisations to probe safety events and could not identify any healthcare provider or setting in its reports. That differs from the NTSB, which can subpoena both witnesses and evidence, and publish detailed accident reports that list locations and companies. A related measure under review by a presidential advisory council would create such a board by executive order. Its details have not been made public. Learning about safety concerns at specific facilities remains difficult. While transportation crashes are public spectacles that make news, creating demand for public accountability, medical errors often remain confidential, sometimes even ordered into silence by court settlements. Meaningful and timely information for consumers can be challenging to find. However, patient advocates said, unsafe providers should not be shielded from reputational consequences. Read full story Source: CNN, 30 May 2023 Related reading on the hub: Blog - It is time for a National Patient Safety Board: Pittsburgh Regional Health Initiative
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Content ArticleAlarms are signals intended to capture and direct human attention to a potential issue that may require monitoring, assessment or intervention. They play a critical safety role in high-risk industries such as healthcare, which relies heavily on auditory and visual alarms. While there are some guidelines to inform alarm design and use, alarm fatigue and other alarm issues are challenges in the healthcare setting. The automotive, aviation, and nuclear industries have used the science of human factors to develop alarm design and use guidelines. This study in the journal Patient Safety aimed to assess whether these guidelines may provide insights for advancing patient safety in healthcare.
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