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Found 324 results
  1. Content Article
    Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. This moving film describes what Connor was like by his friends and family and highlights the failings that caused the avoidable death of Connor.
  2. Content Article
    This presentation written by Dr Gordon Caldwell, a Consultant Physician at Lorn and Islands Hospital, Oban, Argyll, Scotland, highlights the importance of surveillance and actions to be taken around prevention of infection of cannlula sites.
  3. Content Article
    In this blog published in the New York Times, Theresa Brown explains why American healthcare has become one giant workaround.  "The nurses were hiding drugs above a ceiling tile in the hospital — not because they were secreting away narcotics, but because the hospital pharmacy was slow, and they didn’t want patients to have to wait." These 'work arounds ' pose a significant patient safety risk. What work around problems do you have in your department? Theresa Brown is a clinical faculty member at the University of Pittsburgh School of Nursing.
  4. Content Article
    This is a story of a patient in whom the emergency department missed the same diagnosis twice, four years apart. The first occasion (prior to his diagnosis of ankylosing spondylitis) was understandable. The second was not. As a result of this case, the hospital have changed their x-ray policy for non-traumatic back pain. They also want to share key learning points (the majority of which were due to lack of awareness about a relatively rare condition and its complications) as widely as possible, to help others avoid the same errors.  This reflective learning features guest educator, Mr Gareth Dwyer (the patient).
  5. Content Article
    A blog from Dr Linda Dykes. "Bryn was my patient. He died. He may have stood a better chance of survival had I been aware of the risk of small bowel volvulus in an adult.  I produced this reflective learning resource with some colleagues - and with Bryn's widow, whom we call Fiona.  Please read it... it may help you save a life one day."
  6. Content Article
    How we treat each other at work has an enormous impact on how teams perform – with potentially fatal consequences if you work in healthcare. In this TEDx talk, Chris Turner reveals the shocking impact of rudeness in the workplace, arguing that civility saves lives.
  7. Content Article
    Ever wondered what GPs do in a day? Watch this short video to find out.
  8. Content Article
    Ever wondered what a day in the life of a neurosurgeon on-call is like? Watch this video to follow a neurosurgery resident in a UK major trauma centre as he works a 28 hour shift.
  9. Content Article
    Ben Tipney and Vikki Howarths' presetation on Human Factors in practice. This presentation covers: an introduction to human factors human factors training implementation of human factors in practice new initiatives.
  10. Content Article
    In 2019, the US-based National Quality Forum (NQF), is convening a new multi-stakeholder expert committee to revisit and build on the work of the Diagnostic Quality and Safety Committee. This report updates a scan done when the National Quality Framework (NQF) diagnostic measures framework first came out in 2017. The assessment of the current state of diagnostic errors measurement, themes that have emerged since the earlier document and new measures that have been published may be of interest to researchers in the UK doing work in this important segment of patient safety work.
  11. Content Article
    HindSight is a magazine produced by the Safety Improvement Sub-Group (SISG) of EUROCONTROL. It is produced for Air Traffic Controllers and is issued by the Agency twice a year. Its main function is to help operational air traffic controllers to share in the experiences of other controllers who have been involved in ATM-related safety occurrences.  The current Editor in Chief is Dr Steven Shorrock.
  12. Content Article
    Patients' self‐management practices have substantial consequences on morbidity and mortality in diabetes. While the quality of patient‐physician relations has been associated with improved health outcomes and functional status, little is known about the impact of different patient‐physician interaction styles on patients' diabetes self‐management. This study, published by the US Journal of General Internal Medicine, assessed the influence of patients' evaluation of their physicians' participatory decision‐making style, rating of physician communication, and reported understanding of diabetes self‐care on their self‐reported diabetes management.
  13. 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.
  14. Content Article
    International bestseller by Daniel Kahneman, about making decisions. 
  15. Content Article
    In his book, Atul Gawande discusses how today we find ourselves in possession of stupendous know-how, which we willingly place in the hands of the most highly skilled people. However, he notes that avoidable failures are common and the reason is simple: the volume and complexity of our knowledge has exceeded our ability to consistently deliver it - correctly, safely or efficiently. The checklist manifesto shows how the simplest of ideas could transform how we operate in almost any field.
  16. Content Article
    The phrase “lessons learned” is such a common one, yet people struggle with developing effective lessons learned approaches. The Lessons Learned Handbook is written for the project manager, quality manager or senior manager trying to put in place a system for learning from experience, or looking to improve the system they have. Based on experience of successful and unsuccessful systems, the author recognises the need to convert learning into action. For this to happen, there needs to be a series of key steps, which the book guides the reader through. The book provides practical guidance to learning from experience, illustrated with case histories from the author, and from contributors from industry and the public sector.
  17. Content Article
    NHS Resolution has published research on the factors which lead patients to consider a claim for compensation when something goes wrong in their healthcare. Undertaken in partnership with The Behavioural Insights Team (BIT), the research considered the experience reported by 728 patients who agreed to participate in a survey, including 20 who volunteered for a subsequent in depth telephone interview with the BIT team.
  18. Content Article
    The preventable death of Connor Sparrowhawk in July 2013 led to a number of investigations and enquiries into practice at Southern Health NHS Foundation Trust in whose care he died.
  19. Content Article
    Patient engagement improves patient, organisation and health system outcomes, but most research is based on primary care. The primary purpose of this study was to describe the characteristics of published  research that evaluated patient engagement in hospital health service improvement.
  20. Content Article
    Patient-centeredness is central to healthcare. Hospitals should address patients’ unique needs to improve safety and quality. Patient engagement in healthcare, which may help prevent adverse events, can be approached as an independent patient safety practice (PSP) or as part of a multifactorial PSP.  This systematic review by Berger et al., published in BMJ Quality & Safety, examines how interventions encouraging this engagement have been implemented in controlled trials. It found that while patient engagement in safety is appealing, there is insufficient high-quality evidence informing real-world implementation. Further work is needed to evaluate the effectiveness of interventions on patient and family engagement and clarify the added benefit of incorporating engagement in multifaceted approaches to improve patient safety endpoints. In addition, strategies to assess and overcome barriers to patients’ willingness to actively engage in their care should be investigated.
  21. Content Article
    This is the opening lecture of the 2019 PHEM (PreHospital Emergency Medicine) Feedback Showcase event.  It opens with an address from Ms Jacqueline Kelly, Dean of the School of Health and Social Work at the University of Hertfordshire.  It then gives an explanation of what PHEM Feedback is and how it came to exist.
  22. Content Article
    Designed and tested by the Institute for Healthcare Improvement's (IHI) world-renowned safety experts, this toolkit includes documents on improving teamwork and communication, tools to help you understand the underlying issues that can cause errors, and valuable guidance about how to create and maintain reliable systems. Each of the nine tools includes a short description, instructions, an example and a blank template.
  23. Content Article
    Poster summarising the barriers in sharing learning across organisations in healthcare.
  24. Content Article
    Was a lack of situational awareness a contributing factor in the outcome of this 'routine operation'? In this human factors video, Martin Bromiley, a pilot, explains what happened that day and what measures need to be in place to prevent other similar incidents.
  25. Content Article
    For eligible patients, prompt admission to the Intensive Care Unit (ICU) can increase their chance of survival by up to 23%. Yet those that do survive may experience lasting physical and emotional effects, and it is the job of the clinician to carefully weigh up the potential gains and risks of admission in what is often a time-pressured environment. There are currently no national guidelines to help the decision-making process, and evidence suggests it is influenced by a range of factors, with considerable variation between clinicians. In addition, patients and their families are not always fully informed or consulted. This study, published by Health Services and Delivery Research, explored current practice in order to create a decision support tool that could be used to help take some of the uncertainty out of the process, thereby improving decisions and, when possible, also informing the discussions with the patient and their family.
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