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Found 119 results
  1. Content Article
    This blog from Samrina Bhatti, Manager, and Karen Taylor Director, Deloitte Centre for Health Solutions, celebrates World Patient Safety Day 2020 by exploring how the safety of health workers, is a priority for patient safety.
  2. Content Article
    Concerns for patient safety persist in clinical oncology. Within several nonmedical areas (eg, aviation, nuclear power), concepts from Normal Accident Theory (NAT), a framework for analysing failure potential within and between systems, have been successfully applied to better understand system performance and improve system safety. Clinical oncology practice is interprofessional and interdisciplinary, and the therapies often have narrow therapeutic windows. Thus, many of the processes are, in NAT terms, interactively complex and tightly coupled within and across systems and are therefore prone to unexpected behaviours that can result in substantial patient harm. To improve safety at the University of North Carolina, Chera et al. have applied the concepts of NAT to their practice to better understand their systems’ behaviour and adopted strategies to reduce complexity and coupling. Furthermore, recognising that you cannot eliminate all risks, they have stressed safety mindfulness among their staff to further promote safety. Many specific examples are provided herein. The lessons from NAT are translatable to clinical oncology and may help to promote safety.
  3. Content Article
    In this webinar Dr Brian McClean, Clinical Psychologist working with Acquired Brain Injury Ireland, spoke about grading behaviour support plans.
  4. Content Article
    Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating healthcare organisations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission evaluates and accredits more than 22,000 healthcare organisations and programmes in the United States. The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them. The goals are to: Identify individuals served correctly Use medicines safely Prevent infection Identify individuals served safety risks.
  5. Content Article
    Due to COVID-19 and the safety issues the pandemic is highlighting, I have decided to write a sequel to my previous blog 'Dropped instrument, washed and immediately reused'. I am writing this because it recently came to my notice from colleagues that safety is once again being compromised in the same private hospital where my shifts were blocked after I reported a patient safety incident.
  6. Content Article
    The Lilypond is a new conceptual model to describe patient safety performance. It radically diverges from established patient safety models to develop the reality of complexity within the healthcare systems as well as incorporating Safety II principles. There are two viewpoints of the Lilypond that provide insight into patient safety performance. From above, we are able to observe the organisational outcomes. This supersedes the widely used Safety Triangle and provides a more accurate conceptual model for understanding what outcomes are generated within healthcare. From a cross-sectional view, we are able to gain insights into how these outcomes come to manifest. This includes recognition of the complexity of our workplace, the impact of micro-interactions, effective leadership behaviours as well as patterns of behaviour that all provide learning. This replaces the simple, linear approach of The Swiss Cheese Model when analysing outcome causation. By applying the principles of Safety II and replacing outdated models for understanding patient safety performance, a more accurate, beneficial and respectful understanding of safety outcomes is possible.
  7. News Article
    Several mental health trusts have reported spikes in incidents of physical restraint or seclusion on patients, driven by COVID-19 restrictions, HSJ has learned. Concerns have been raised nationally about the potential for incidents to increase during the pandemic, due to temporary measures which have had to be introduced such as visiting restrictions and communication difficulties due to personal protective equipment. Read full story Source: HSJ, 5 June 2020
  8. Content Article
    Read the latest episode in a series of podcasts from the Clinical Human Factors Group giving tips from frontline staff working with Covid patients.
  9. News Article
    Change course or a quarter of a million people will die in a "catastrophic epidemic" of coronavirus – warnings do not come much starker than that. The message came from researchers modelling how the disease will spread, how the NHS would be overwhelmed and how many would die. The situation has shifted dramatically and as a result we are now facing the most profound changes to our daily lives in peacetime. This realisation has happened only in the past few days. However, it is long after other scientists and the World Health Organization had warned of the risks of not going all-out to stop the virus. Read full story Source: BBC News, 18 March 2020
  10. News Article
    Hundreds of elderly and vulnerable social care residents have allegedly been sexually assaulted in just three months, a shock new report from the care regulator has revealed. According to the Care Quality Commission there were 899 sexual incidents reported by social care homes between March and May 2018. Almost half were categorised as sexual assault. In 16% of the cases members of staff or visiting workers were accused of carrying out the abuse. The watchdog said it was notified of 47 cases of rape and told The Independent local authorities were informed and 37 cases were referred to police for investigation. Kate Terroni, Chief Inspector of adult social care at the regulator, said: “Supporting people as individuals means considering all aspects of a person’s needs, including sexuality and relationships. However, our report also shows all too starkly the other side of this – the times when people are harmed in the very place they should be kept safe. This is utterly devastating, both for the people directly affected and their loved ones." “It is not good enough to put this issue in a ‘too difficult to discuss’ box. It is particularly because these topics are sensitive and complex that they should not be ignored.” Read full story Source: The Independent, 27 February 2020
  11. Content Article
    Kathy Nabbie reflects on the recent flights caught up in Storm Dennis and how 'routine' quickly became 'out of the ordinary'. As with aviation, in surgery we must always do the safety checks for each patient to ensure that every journey for the patient is a safe one.
  12. News Article
    Patients who abuse NHS staff will be banned from receiving non-emergency care as new figures show more than one in four NHS staff have experienced harassment, bullying or abuse from patients, relatives or members of the public. The annual survey of more than 560,000 NHS workers found one in seven staff (15%) had experienced physical violence in the last 12 months while 40,000 staff (7.2%) had faced some form of discrimination during 2019 – an increase from 5.8% in 2015. A total of 13% of staff reported being bullied, harassed or abused by their own manager in the past 12 months and almost a fifth (19%) said they had experienced abuse from colleagues. The health secretary Matt Hancock has written to staff condemning the abuse and warning assaults on NHS workers will not be tolerated. Under new plans NHS England said that from April NHS hospitals will be able to bar patients who inflict discriminatory or harassing behaviour on staff from receiving non-emergency care. Previously, individual NHS organisations could only refuse services to patients if they were aggressive or violent. Hospitals will be required to act reasonably and take into account the mental health of the patient or member of the public. Read full story Source: The Independent, 19 February 2020
  13. News Article
    The Doctors’ Association UK has compiled stories from 602 frontline doctors which expose a startling culture of bullying and overwork in the NHS. The stories include: a pregnant doctor who fainted after being forced to stand up for 15 hours straight and being denied water. The junior doctor was subsequently shouted at in front of colleagues and patients on regaining consciousness and told it was her choice to be pregnant and that ‘no allowances would be made’. a doctor who told us that a junior doctor hung themselves in a cupboard whilst on shift and was not found for 3 days as no-one had looked for them. His junior doctor colleagues were not allowed to talk about his suicide and it was all ‘hushed up’. a doctor who was denied a change of clothes into scrubs after having a miscarriage at work despite her trousers being soaked in blood. Full press release
  14. News Article
    There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the years. Some patient safety progress has been made, but not enough when the history of NHS policy making in the area is analysed. Lessons going unlearnt from previous patient safety event crises is also an acute problem. Patient safety events seem to repeat themselves with the same attendant issues. Read full story Source: Harvard Law, 17 February 2020
  15. Content Article
    Despite dealing with biomedical practices, infection prevention and control (IPC) is essentially a behavioural science. Human behaviour is influenced by various factors, including culture. This paper by M.A. Borg, published in the Journal of Hospital Infection, analyses the cultural determinants of infection control behaviour.
  16. Content Article
    Patient safety event reporting systems are a mainstay in non-punitive reporting of near misses and adverse events. The authors of this study, published in the American Journal of Surgery, hypothesised that an upgraded reporting system that included the ability to report positive behaviours would increase behavioural reports in the perioperative environment. After implementation of an upgraded reporting system that includes an option for positive reporting, the number and length of reports increased. The authors believe that a robust reporting system has contributed to a culture of safety at their institution.
  17. Content Article
    A frank account from a healthcare assistant on the bullying she experienced after raising concerns at the care home she worked in.
  18. Content Article
    'Hospitals should remove any barriers to doctors eating and drinking during the working day'. As healthcare providers, it’s easy to forget to look after ourselves at work. We know that taking breaks and eating and drinking regularly is a critical component of being “optimised,” helping to sustain our energy, concentration and performance, and reduce the risk of human error. Yet, for many, the realities of working in busy, modern hospitals get in the way. Medicine is a demanding profession, with days often starting early and finishing late and many fall into the habit of forgetting to take regular breaks, not drinking enough fluids, or missing meals. If we want to improve staff wellbeing and reduce the risk of errors, we need to change this.
  19. Content Article
    Technology is often viewed as either positive or negative. On one hand weight loss apps are usually seen as a positive influence on users. From the sociocultural perspective, on the other hand, media and technology can negatively impact body satisfaction and contribute to eating disorders; however, these studies fail to include weight loss apps. While these apps can be beneficial to users, they can also have negative effects on users with eating disorder behaviours. Yet few research studies have looked at weight loss apps in relation to eating disorders. In order to fill this gap,these researchers conducted interviews with 16 women with a history of eating disorders who use(d) weight loss apps. While findings suggest these apps can contribute to and exacerbate eating disorder behaviours, they also reveal a more complex picture of app usage. Women’s use and perceptions of weight loss apps shift as they experience life and move to and from stages of change. This research troubles the binary view of technology and emphasises the importance of looking at technology use as a dynamic process. This study contributes to the understanding of weight loss app design.
  20. Content Article
    The Cynefin framework is a conceptual framework used to aid decision-making. Created in 1999 by Dave Snowden when he worked for IBM Global Services, it has been described as a "sense-making device". Cynefin is a Welsh word for habitat. The Cynefin Framework allows executives to see things from new viewpoints, assimilate complex concepts, and address real-world problems and opportunities. Using the Cynefin framework can help executives sense which context they are in so that they can not only make better decisions but also avoid the problems that arise when their preferred management style causes them to make mistakes. In this video, Dave Snowden introduces the Cynefin Framework with a brief explanation of its origin and evolution and a detailed discussion of its architecture and function.
  21. Content Article
    Not all leaders achieve the desired results when they face situations that require a variety of decisions and responses. All too often, managers rely on common leadership approaches that work well in one set of circumstances but fall short in others. Why do these approaches fail even when logic indicates they should prevail? The answer lies in a fundamental assumption of organisational theory and practice: that a certain level of predictability and order exists in the world. This assumption, grounded in the Newtonian science that underlies scientific management, encourages simplifications that are useful in ordered circumstances. Circumstances change, however, and as they become more complex, the simplifications can fail. Good leadership is not a one-size-fits-all proposition as David J. Snowden and Mary E. Boone discuss in this article for the Harvard Business Review. They look at the 'Cynefin framework' which allows executives to see things from new viewpoints, assimilate complex concepts, and address real-world problems and opportunities.
  22. Content Article
    This edited book concerns the real practice of human factors and ergonomics (HF/E), conveying the perspectives and experiences of practitioners and other stakeholders in a variety of industrial sectors, organisational settings and working contexts. The book blends literature on the nature of practice with diverse and eclectic reflections from experience in a range of contexts, from healthcare to agriculture. It explores what helps and what hinders the achievement of the core goals of HF/E: improved system performance and human wellbeing.
  23. Content Article
    Harold Shipman was an English doctor who killed approximately 15 patients while working as a junior hospital doctor in the 1970s, and another 235 or so when working subsequently as a general practitioner. Is it possible to learn general lessons to improve patient safety from such extraordinary events? In this paper, published in the US Journal of the Royal Society of Medicine, it is argued that it is not possible fully to understand how Shipman came to be such a successful and prolific serial killer, nor to learn how the safety of healthcare systems can be improved, unless his diabolical activities are studied using approaches developed to investigate patient safety.
  24. Content Article
    A safety culture is built on trust. It empowers staff to report errors, near misses, and recognise unsafe behaviours and conditions that can put patients at risk, all of which drive improvement.   This video by the Joint Commission Centre for Transforming Healthcare explains how they are engaging staff and the importance of speaking up.
  25. Content Article
    What happens if a surgeon accidentally drops an instrument on the floor, picks it up and reuses, without it going through a steriliser? Should this be allowed to happen? Well it did! 
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