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Showing results for tags 'High reliability organisations'.
Found 33 results
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Content ArticleA new MIT study identifies six systemic factors contributing to patient hazards in laboratory diagnostics tests. By viewing the diagnostic laboratory data ecosystem as an integrated system, MIT researchers have identified specific changes that can lead to safer behaviours for healthcare workers and healthier outcomes for patients.
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Content ArticleIn the UK and several other countries, including Norway, Australia and New Zealand, operators of safety-critical systems, such as nuclear power plants, public transportation systems and defence equipment, must develop a safety case to demonstrate that their systems are acceptably safe to operate. In these countries, the development, review and maintenance of safety cases are regulatory requirements. In the NHS in England, manufacturers of health information technology have been required to submit clinical safety cases since 2013. However, this is a domain with a narrow technological focus and limited organisational support. Mark Sujan and Ibrahim Habli discuss why they think safety cases would be a valuable addition to Safer Clinical Systems and patient safety practice?
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Content ArticleHigh reliability organisations are organisations that work in situations that have the potential for large-scale risk and harm, but which manage to balance effectiveness, efficiency and safety. They also minimise errors through teamwork, awareness of potential risk and constant improvement. This evidence scan collates empirical evidence about the characteristics of high reliability organisations and how these organisations develop within and outside healthcare.
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Content ArticleClive Flashman, Patient Safety Learning's Chief Digital Officer, shares his presentation slides from the Health Plus Care 2022 conference. The presentation slides include basic principles, how to involve the patient and public in design, key issues and Clive's ten top tips for digital health innovators.
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Content Article
Rethinking healthcare as a safety-critical industry
Patient Safety Learning posted an article in Barriers
The discipline of ergonomics, or human factors engineering, has made substantial contributions to both the development of a science of safety, and to the improvement of safety in a wide variety of hazardous industries, including nuclear power, aviation, shipping, energy extraction and refining, military operations, and finance. It is notable that healthcare, which in most advanced societies is a substantial sector of the economy and has been associated with large volumes of potentially preventable morbidity and mortality, has not up to now been viewed as a safety critical industry. This paper from Robert L Wears proposes that improving safety performance in healthcare must involve a re-envisioning of healthcare itself as a safety-critical industry, but one with considerable differences from most engineered safety-critical systems. This has implications both for healthcare, and for conceptions of safety-critical industries. -
Content ArticleSleep deprivation and fatigue lead to a wide range of performance issues that may pose risks to workers and others in the work environment. This review in Frontiers in Neuroscience discusses relevant literature on the topic of fatigue-related performance effects, with a special emphasis physiological and behavioural response variables that have shown to be sensitive to changes in fatigue. It also looks at methods for mitigating these performance effects and discusses their usefulness in regulating them.
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Content Article
In a series of blogs for the hub, Emma Plunkett and Nancy Redfern, part of the Joint Working Group on Fatigue, will highlight the impact staff fatigue has not only on the staff themselves but also on patient safety, and why healthcare needs a robust fatigue risk management system like other safety-critical industries. In their first blog, Emma and Nancy share how they became involved in investigating night shift fatigue after the death of a colleague driving home tired. They discuss how they set up the Joint Working Group on Fatigue and the aims of the #FightFatigue campaign. -
Content Article
Guiding principles for determining work shift duration and addressing the effects of work shift duration on performance, safety, and health: guidance from the American Academy of Sleep Medicine and the Sleep Research Society (1 November 2021)
Patient-Safety-Learning posted an article in Workforce and resources
Regulators, organisations, communities and workers often struggle with how to manage shift duration and address associated risks from fatigue and sleepiness, while continuing to meet the societal demands for work. This article in the Journal of Clinical Sleep Medicine proposes a series of guiding principles help design a shift duration decision-making process that effectively balances the need to meet operational demands with the need to manage fatigue-related risks. -
Content ArticleThe Leapfrog Group is a non-profit watchdog organisation that serves as a voice for healthcare consumers in the US, using their collective influence to foster positive change in healthcare. It provides patient safety ratings for hospitals, grading them from A to E. This article in Becker's Hospital Review highlights the patient safety priorities for 2023 of eleven US hospitals that have consistently been awarded 'A' grades by Leapfrog. Key themes include a focus on reducing healthcare associated infections, increasing psychological safety for staff and improving communication between staff and patients.
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Content ArticleThis article in Time reviews the documentary film 'To Err is Human', which explores the tragic outcomes of medical errors and the medical culture that allows them to persist. The film follows the Sheridans, a family from Boise, Idaho on their journey to understand how two major medical errors befell their family: one that contributed to a case of cerebral palsy, and another that involved a delayed cancer diagnosis and ended in death.
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Content ArticleThis study in BMJ Open Quality examines aspects of workplace culture, employee motivation and leadership behaviours that support continuous learning and improvement, in an effort to measure the transition to high reliability. It reports on the development of two scales (trust in team members and trust in leadership) in a US children’s hospital which was seeking to assess progressive movement towards a ‘culture of safety'. The scales were designed to measure two cultural conditions fostered by the five high reliability principles and a composite measure on local learning activities.
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Content ArticleThis open access book addresses the future of work and industry by 2040—a core interest for many disciplines inspiring a strong momentum for employment and training within the industrial world. The future of industrial safety in terms of technological risk-management, although of obvious concern to international actors in various industries, has been quite sparsely addressed. This brief reflects the viewpoints of experts who come from different academic disciplines and various sectors such as oil and gas, energy, transportation, and the digital and even the military worlds, as expressed in debates and discussions during a two-day international seminar. 'Managing future challenges for safety' will interest and influence researchers considering the future effects of a number of currently developing technologies and their practitioner counterparts working in industry and regulation.
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Content ArticleFor two decades, Swiss Cheese theory has been an influential metaphor in safety science and accident prevention. It has made barrier theory and the impact of safety culture on operational safety more understandable to the upper echelons of high-risk organisations in many industrial sectors. Yet sometimes the Swiss Cheese model is used to focus on the operational ‘sharp end’ and unsafe acts, like a magnifying glass that acknowledges organizational influence, but still targets the human operator. It is time to ‘turn this lens around and allow organisations to focus on the upstream factors and decision-making that can engender these unsafe acts in the first place. This paper reports on an approach to do this, under development in the Maritime sector, called Reverse Swiss Cheese.
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Event
Human Factors in accident investigation
Patient Safety Learning posted an event in Community Calendar
untilThis free webinar will uncover the intricacies of accident investigation from a human factors perspective. It will feature examples from rail, air and maritime from our speakers who are all specialist human factors investigators. Hear first hand how they tackle investigations and get insights into this vital work that lead to improvements in safety across all travel sectors. Will Tutton will briefly mention the Herald of Free Enterprise, but will mainly talk about the cargo vessel Kaami, which ran aground in Scotland in March 2020. The investigation focused on front line operators. Lisa Fitzsimons will talk about common themes relating to human performance and organisational factors which emerge when investigating the technical aspects of an air accident, drawing upon several recent examples. Becky Charles will discuss track worker safety and specifically about an incident which occurred at Margam, UK in July 2019 where two trackworkers were struck and fatally injured. Register -
Content Article
Skybrary: Safety Management System in aviation
Patient Safety Learning posted an article in Organisational
The objective of a Safety Management System is to provide a structured management approach to control safety risks in operations. Effective safety management must take into account the organisation’s specific structures and processes related to safety of operations. -
Content ArticleProfessor Ron McLeod's presentation on the Chartered Institute of Ergonomics & Human Factors (CIEHF) White Paper on Human Factors in highly automated systems.
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Content ArticleClinical engagement has supplemented clinical governance in healthcare to strengthen the contribution of medical professionals to the assessment of clinical outcomes for patients. Assessments of clinical engagement have, until now, been qualitative; this case study in the journal Australian Health Review introduces the concept of quantitative assessment of clinical engagement by measuring the number of patients managed according to specialist society guidelines. Such an assessment engages all staff (medical, nursing, allied health and pharmacy) involved in patients receiving treatment according to such guidelines and provides an assessment of individual and organisational compliance with those guidelines. Clinical engagement is then quantified as the percentage of patients that have been documented to receive specialist society- or college-approved guideline-compliant treatment, relative to the total number who could receive such treatment, in any healthcare organisation.
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Content ArticleThis Chartered Institute of Ergonomics and Human Factors (CIEHF) webinar explores near misses in three different sectors and how controls can, or cannot, be developed to prevent future events.
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Content ArticleHuman error is as old as humankind itself and widely recognised as a significant cause of mistakes. Much of the research in this area has originated from high-risk organisations (HROs), including commercial aviation, where even simple mistakes can be catastrophic. A failure to understand and recognise how Human Factors (HF), especially those that affect performance and team working, can contribute or lead to serious medical error is still widespread across healthcare. Sadly, this commonly occurs in the operating theatre, one of the most dangerous places in hospital. While attitudes and acceptance of pre-surgery briefings has improved using the World Health Service (WHO) Surgical Checklist, this does not address other 'personal' factors that can lead to error, including stress, fatigue, emotional status, hunger and situational awareness. Following initial work around HF perception amongst operating theatre teams, Peter Brennan's (student at the University of Portsmouth) research has lead to significant delivery changes to the high stakes Membership of the Royal College of Surgeons (MRCS) examination, taken by up tp 6,500 junior doctors per year. After recognising boredom and fatigue in examiners, further published studies found an improvement in examiner morale with no significant changes in exam reliability or overall candidate outcome. These changes have improved patient safety at a National level. Other high stakes National Events have been evaluated where repetitive assessment occurs during long days, providing reassurance to organisers and the General Medical Council. 28 HF-related publications have been included in this work, including several reviews of important personal factors that affect performance and how these can be optimised at work.
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Content ArticleKrista Haugen is National Director of Patient Safety for US-based emergency and patient relocation services provider Global Medical Response. In this interview, she describes how her 25-year career as an emergency medicine nurse has influenced her approach to safety and patient care. She discusses her personal experience of being involved in an accident as an air-ambulance flight nurse, and how this caused her to look at safety and risk management from a systems perspective, focussing on building a just culture where safety is optimised through organisational reflection and learning.
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Content ArticleEurocontrol’s HindSight magazine is a magazine on human and organisational factors in operations, in air traffic management and beyond. This issue has articles from front-line staff and specialists in safety, human factors, and human and organisational performance, in aviation and elsewhere. The articles cover all aspects of everyday work, including routine work, unwanted events, and excellence. The authors discuss a variety of ways to learn from everyday work, including observation, discussion, surveys, reflection, and data analysis. There are articles on specific topics to help learn from others’ experience, including from other sectors in ‘views from elsewhere’
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EventObjectives: Describe the steps involved in conducting RCA of an error. List the tools that can be used during the RCA process. Identify who should be included on a debriefing team and what the ground rules are that will allow a debriefing meeting to be most effective. Register
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Content ArticleStep Change in Safety is a member-led organisation which is working to make the UKCS the safest oil and gas province in the world in which to work. The safety of the workforce always comes first. Through collaboration, sharing knowledge and adopting best practices, workforce safety in the UKCS can be continually improved and Step Change in Safety are at the forefront in delivering that. Take a look at Step Change in Safety's resources and see how they could apply to healthcare.
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EventuntilIt’s time to register for the 2022 World Patient Safety, Science & Technology Summit, hosted by Patient Safety Movement in the USA. The 2022 World Patient Safety, Science & Technology Summit (WPSSTS) is co-convened by the American Society of Anesthesiologists, the European Society of Anaesthesiology and Intensive Care and the International Society for Quality in Health Care, and will celebrate the Patient Safety Movement Foundation’s first 10 years of achievements. The 2022 WPSSTS will confront leading patient safety issues with actionable ideas and innovations to transform the continuum of care by dramatically improving patient safety and eliminating preventable patient harm and death. The WPSSTS brings together all stakeholders; we need everyone to step up and be part of the solution. We invite international hospital leaders, patient and family member advocates who have experienced harm, public policymakers and government officials, other non-profits working toward zero harm, healthcare technologists, engineers, and the future of healthcare – students and residents. All stakeholders are invited to actively and intimately plan solutions around the leading patient safety challenges that cause preventable patient deaths in hospitals and healthcare organizations worldwide. The WPSSTS will also feature keynote addresses from public figures, patient safety experts, and plenary sessions with healthcare luminaries, patient advocates, as well as announcements from organizations who have made their own commitments to reach the Patient Safety Movement Foundation’s vision of ZERO preventable harm and death across the globe by 2030. Event timings: 4 March 2022 8.00 am PST (4.00pm GMT) - 5 March 2022 5.00 pm PST (6 March 1.00am GMT) Buy tickets
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Content ArticleHealthcare can be risky. Adverse events carry a high cost – both human and financial – for health systems around the world. So in an effort to improve safety, many health systems have looked to learn from high-risk industries. The aviation and nuclear industries, for example, have excellent safety records despite operating in hazardous conditions. And increasingly, the tools and procedures these industries use to identify hazards are being adopted in healthcare. One prominent example involves the Hierarchy of Risk Controls (HoC) approach, which works by ranking the methods of controlling risks based on their expected effectiveness. According to HoC, the risks at the top are presumed to be more effective than those at the bottom. The ones at the top typically rely less on human behaviour: for example, a new piece of technology is considered to be a stronger risk control than training staff. This article looks more deeply at the (HoC) approach to explore its usefulness and effectiveness in healthcare. To investigate this issue, a team of social scientists examined the risk controls introduced by four hospital teams in England and Scotland after they had identified hazards in their systems.
