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Found 235 results
  1. Content Article
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    SLIPPS is responding to the challenge to improve European patient safety competence and education. Errors, mishaps and misunderstandings are common and around 1 in 10 patients suffer avoidable harm (WHO 2014). The majority of adverse care episodes and near misses are preventable (Vlayen et al 2012) and such incidents impact upon patients, their families, health care organisations, staff and students.
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    The results, published in BMJ Safety & Quality, found that fewer moderate-severe IMG-related errors occurred with the user-tested guidelines compared with current guidelines, but this difference was not statistically significant. Significantly more simulations were completed without any IMG-related errors with the user-tested guidelines compared with current guidelines. Participants who used user-tested guidelines reported greater confidence. The authors conclude that user-testing injectable medicines guidelines reduces the number of errors and the time taken to prepare and administer intravenous medicines, while increasing staff confidence.
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    In this article, Dan looks back at the Donabedian Model, a framework for measuring healthcare quality, and suggests why this might be an over simplification and why we must also look at human factors when we think about patient safety. We are humans and we can, do and will make mistakes, so we have a personal responsibility to acknowledge and address this as a contributing factor for patient safety incidents and harm. How do we begin to address our individual responsibilities? How can each of us reduce the personal risks we pose for our patients? How do we begin to address the moral imperative to recognise and then overcome any professional complacency that may interfere with our performance? Dan believes by enhancing human performance within healthcare settings this will serve as the ultimate key to improving quality and safety. Recognition by clinicians of their own tendencies toward complacency and their own vulnerabilities toward making mistakes is to encompass a mandate for personal professional commitment and improvement. If patients are harmed on the frontlines in healthcare settings, then it is on the frontlines that many of the solutions can be found and safety improvements nurtured. First recognising, and then modulating, the human factors liabilities that exist on the frontlines and overcoming the challenges of professional complacency will be necessary steppingstones towards sustained improvements in providing patient safe care. Clinicians, managers and leaders need to work collaboratively to understand and overcome the challenges that human factors pose when addressing individual performance.
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    This document presents a basic description of ten topic areas relating to organizational and human factors influencing patient safety. It also identifies a selection of tools for the measurement or training of these factors which may be suitable for application in developing, as well as developed, countries. The ten topics are: organisational safety culture managers’ leadership communication team (structures and processes) team leadership (supervisors) situation awareness decision making stress Fatigue work environment.
  17. Content Article
    What Human Factors isn’t: 1. Common Sense What Human Factors isn’t: 2. Courtesy and Civility at Work What Human Factors isn’t: 3. Off-the-shelf Behaviour Modification Training What Human Factors isn’t: 4. A cause of accidents.
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    From the 5365 operations, 188 adverse events were recorded. Of these, 106 adverse events (56.4%) were due to human error, of which cognitive error accounted for 99 of 192 human performance deficiencies (51.6%). These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.
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