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Found 323 results
  1. 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.
  2. 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.
  3. Content Article
    Sepsis can be difficult to spot or articulate. This short video by MiXiT days, a theatre company made up of people with and without learning difficulties, describes the symptoms of sepsis in song format.
  4. 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.
  5. Content Article
    There has been an identified need for greater patient and family member involvement in healthcare. This is particularly relevant in an intensive care unit (ICU), as the family provides a key communicative and practical link between patient and clinician. Family members have been deemed a positive beneficial influence on ICU care and recovery processes, yet they themselves are often emotionally affected after discharge. There has been no standardised evidenced-based approach which explores research on family member involvement and the range and quality of contributions remain unclear. This study from Xyrichis et al. undertook a systematic review to assess the evidence base for interventions designed to promote patient and family member involvement in adult intensive care settings and develop a comprehensive typology of interventions for use by clinicians, patients and carers. The review provides valuable and rigorous insight into the range and quality of interventions available to promote patient and family member involvement in ICU. This is the first step towards addressing the absence of a synthesis of research for this context, and will, in addition, develop a typology of available interventions that will help service users and clinicians make informed decisions about the approaches to patient and family member involvement which they might want to adopt.
  6. Content Article
    Healthcare is in the midst of significant change, with substantial shifts in emphasis and priorities. Patient-centered care has become central to the core goals of better health, better quality, and lower costs while highlighting the necessity of incorporating patients’ efforts, needs, and perspectives into healthcare at all levels. Patient and family engagement (PFE) is critical to patient-centered care, and important theoretical and empirical work has identified key elements and implications of PFE, especially for management of chronic illnesses and preference-sensitive clinical decision making. Brown et al. believe that the ultimate goal of active, mutually respectful partnership among clinicians and patients/families is urgent and important. However, consistent terminology and definitions of PFE are still lacking. This deficit is particularly striking in intensive care units (ICUs), which pose special challenges to outpatient models of PFE: the emotional stakes are high, time is greatly compressed, surrogates play a central role, and the specter of death often dominates decision making.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. Content Article
    The vast majority of healthcare is provided safely and effectively. However, just like any high-risk industry, things can and do go wrong. There is a world of advice about how to keep people safe but this delivers little in terms of changed practice. Written by Suzette Woodward, a leading expert in the field with over two decades of experience, Rethinking Patient Safety provides readers with a critical reflection upon what it might take to narrow the implementation gap between the evidence base about patient safety and actual practice. This book provides important examples for the many professionals who work in patient safety but are struggling to narrow the gap and make a difference in their current situation. It provides insights on practical actions that can be immediately implemented to improve the safety of patient care in healthcare and provides readers with a different way of thinking in terms of changing behaviour and practices as well as processes and systems. Suzette Woodward shares lessons from the science of implementation, campaigning and social movement methods and offers the reader the story of a discovery. Her team has explored an approach which could profoundly affect the safety culture in healthcare; a methodology to help people talk to each other and their patients and to listen through facilitated safety conversations. This is their story.
  13. 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.
  14. 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.
  15. Content Article
    In this paper, Kurtz and Snowden challenge the universality of three basic assumptions prevalent in organisational decision support and strategy: assumptions of order, of rational choice, and of intent. They describe the Cynefin framework, a sense-making device they have developed to help people make sense of the complexities made visible by the relaxation of these assumptions. The Cynefin framework is derived from several years of action research into the use of narrative and complexity theory in organisational knowledge exchange, decision-making, strategy, and policy-making. The framework is explained, its conceptual underpinnings are outlined, and its use in group sense-making and discourse is described. Finally, the consequences of relaxing the three basic assumptions, using the Cynefin framework as a mechanism, are considered.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. Content Article
    The great majority of medical diagnoses are made using automatic, efficient cognitive processes, and these diagnoses are correct most of the time. This analytic review from Berner and Graber in The American Journal of Medicine concerns the exceptions: the times when these cognitive processes fail and the final diagnosis is missed or wrong. The authors argue that physicians in general underappreciate the likelihood that their diagnoses are wrong and that this tendency to overconfidence is related to both intrinsic and systemically reinforced factors. They present a comprehensive review of the available literature and current thinking related to these issues. The review covers the incidence and impact of diagnostic error, data on physician overconfidence as a contributing cause of errors, strategies to improve the accuracy of diagnostic decision making, and recommendations for future research.
  21. Content Article
    Poster summarising the barriers in sharing learning across organisations in healthcare.
  22. 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.
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