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Showing results for tags 'Human factors'.
Found 552 results
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Tracey talks to us about how her love of applying psychology led to her role in patient safety, the importance of putting users at the centre of developing the Patient Safety Incident Response Framework (PSIRF), and what we can learn from magicians about patient safety.- Posted
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Content ArticleThis study in Plos One used a prospective error analysis method—the Systematic Human Error Reduction and Prediction Approach (SHERPA)—to examine the process of dispensing medication in community pharmacy settings and identify solutions to avoid potential errors. These solutions were categorised as strong, intermediate or weak based on an established patient safety action hierarchy tool. The authors identified 88 potential errors with a total of 35 remedial solutions proposed to avoid these errors in practice. Sixteen (46%) of these remedial measures were categorised as weak, 14 (40%) as intermediate and 5 (14%) as strong according to the Veteran Affairs National Centre for Patient Safety action hierarchy. The authors suggest that future research should examine the effectiveness of the proposed remedial solutions to improve patient safety.
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Event
Red Teams to improve patient safety
Patient Safety Learning posted an event in Community Calendar
The new NHS Patient Safety Syllabus has brought education and training to the fore to push patient safety in healthcare. Based on the syllabus this masterclass will focus on how Human Factors and Red Teams can be improve patient safety. Red Teams are defined as a team that is formed with the objective of subjecting an organisation’s plans, programmes, ideas and assumptions to rigorous analysis and challenge. It will look at the use of Red Teaming taken from the Ministry of Defence for supporting staff and teams faced with different problems and challenges in healthcare. It will look at how you can use these techniques to improve problem solving and making decisions across all levels of the organisations. Red Teaming is the independent application of a range of structured, creative and critical thinking techniques to assist healthcare staff make a better-informed decision or produce a more robust product. Finally, it will address problems and develop capability within healthcare organisations. It introduces more formal analytical techniques that can be used with more complex problems when more time is available. Register hub members receive a 20% discount. Email info@pslhub.org for discount code. -
EventuntilEmail rduh.qit@nhs,net to book a place.
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Content ArticleRoyal Cornwall QI conference online book supporting the conference. The online brochure highlights all the quality improvement projects at Royal Cornwall Hospitals.
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Content Article
Did you know? Extravasation (November 2022)
Patient_Safety_Learning posted an article in Extravasation
Extravasation is the accidental leakage of any liquid from a vein into the surrounding tissues, which can cause serious harm to the patient (NHS England, 2017). From 1 April 2011 until 31 March 2021 the NHS paid £15.6 million in damages relating to extravasation. This leaflet, published by NHS Resolution, aims to share learning from those claims. -
Content ArticleHuman factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system. This article explores how HFE can be used to improve patient safety, in particular using the Systems Engineering Initiative for Patient Safety (SEIPS) model, which depicts key characteristics and interactions between three core components: work system process outcomes
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Content ArticleThis blog is part of a series in which Steven Shorrock, an interdisciplinary humanistic, systems and design practitioner, outlines seven ‘archetypes of human work’. This blog looks specifically at 'The Messy Reality' archetype, which is characterised by adjustments, adaptations, variations, trade-offs, compromises and workarounds that are hard to prescribe and hard to identify, but that can become accepted and unremarkable for insiders. Steven examines what 'The Messy Reality' is, why it exists and highlights some examples from the aviation and healthcare industries.
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Content ArticleThis webinar hosted by the National Orthopaedic Alliance (NOA) gives a brief overview of human factors and ergonomics, its relevance and role in improving patient safety, how it has been embedded in one organisation and the impact it has had. Fran Ives, Human Factors Specialist and part of the Human Factors team at the Robert Jones and Agnes Hunt Hospital (RJAH) speaks about her experience of applying Human Factors both within a large NHS Trust and an Academic Health Science Network, including the successes and challenges of setting up and developing a service, and what difference such a service can make.
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Content ArticleThe Patient Safety Database (PSD), previously called the Anesthesia Safety Network, is committed in the delivery of better perioperative care. Its primary goal is to make visible the lack of reliability of healthcare and the absolute necessity to build a new system for improving patient safety. This year, PSD has also been involved in the development of the SafeTeam Academy, an e-learning training platform associated with the Patient Safety Database, which offers video immersive courses using the power of cinema to train healthcare professionals. This is the latest newsletter from PSD, featuring a wide range of content by safety experts across Europe.
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Content ArticleVideo recording and slides of a webinar presented by Mary Dixon-Woods, Professor of Medical Sociology and Wellcome Trust Investigator.
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Content ArticleBehind the scenes at one of the UK’s biggest hospitals as it transitions from old to new. The Royal Liverpool University Hospital moves thousands of patients and staff to a new building. This programme documents their journey, the challenges faced and human factors involved.
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Content ArticleMost healthcare systems across the globe are dealing with the reality of limited resources and staffing shortages. Therefore, it is more important than ever to ensure that health care professionals spend time on doing what matters most and providing the most value for service users. Meaningful time spent face to face is a high priority for both service users and health care professionals. Paying more attention to computers than people because of the demands of burdensome documentation diverts our attention from direct care. It is a situation that is unsatisfactory for all parties. The Danish municipality of Sønderborg, a safety leader in nursing home and home-based care for more than a decade, decided to see what could be done. With improvement science already embedded in their organisation, they decided to take a deep dive into their processes as a first step. Mistakes in documentation, coordination, and communication have been identified as among the top 10 of root causes of patient safety incidents in Denmark, so it made sense to start there. Patient safety is often cited as the reason for documentation, but some research indicates that burdensome documentation is associated with increased medical errors, mistakes in documentation, and burnout among health care providers. Working from the theory that safely simplifying or streamlining documentation would free up time for direct care, Sønderborg and the Danish Society for Patient Safety embarked on an improvement journey that started with understanding the workflow of documentation that enabled staff to seek and share information from one another to plan and perform different tasks.
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Gallery Image
Noradrenaline and tranexamic acid.jpg
Patient Safety Learning posted a gallery image in Medication
Shared with hub by Dr Abigail Clark-Morgan: Images shared of our stocked noradrenaline ampules and tranexamic acid – these have been mixed up and we are looking to stock alternative volumes of noradrenaline to reduce the likelihood of confusion. The incident also highlighted the importance of checking all the ampules drawn up, drawing up your own medications at the point of administration and effective second checking. Part of our immediate response was to label the noradrenaline ampules to make them more obviously different (the purple ampules pictured below).© Healthcare UK
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Content ArticleSteven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. In this blog, he reflects on what he has learned from 25 years as a human factors expert, highlighting that human factors is essentially about improving work, via design.
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Content ArticleThis download is the second of three chapters of a book which complements the Chartered Institute of Ergonomics and Human Factors' Healthcare Learning Pathway and is intended as a practical resource for students.
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Content ArticleThe third leading cause of death in the US is its own healthcare system—medical errors lead to as many as 440,000 preventable deaths every year. To Err Is Human is an in-depth documentary about this silent epidemic and those working quietly behind the scenes to create a new age of patient safety. Through interviews with leaders in healthcare, footage of real-world efforts leading to safer care, and one family’s compelling journey from being victims of medical error to empowerment, the film provides a unique look at the US healthcare system’s ongoing fight against preventable harm.
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Content ArticleIn 1999, the pivotal report “To Err is Human” by the Institute of Medicine led to sweeping changes in healthcare. This report outlined how blaming individuals does not change the underlying factors that contribute to medical errors. It also stated that blaming an individual does little to make the system safer – or prevent someone else from similar errors. It is unusual for a nurse to be charged criminally, when there is no intent to harm a patient. However, the recent trial in America of nurse RaDonda Vaught could set a precedent for future medical errors to be treated as criminal cases. The case may ensure that for every step that has been taken forward in patient safety, we have now taken two steps backwards. This article from Human Factors 101 looks at the case of RaDonda Vaught, the criminal trial and conviction, and discusses the impact this will have on healthcare.
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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 Article
Blog - Is human error a crime? (2 November 2022)
Patient-Safety-Learning posted an article in Legal matters
Martin Anderson, author of the Human Factors 101 blog, looks at the case of US nurse RaDonda Vaught, who was found guilty of criminally negligent homicide and abuse of an impaired adult following a medication error that led to a patient death in 2017. He provides a timeline of the events that occurred in the run up to the criminal trial and highlights concerns that the case will set a precedent in bringing criminal charges against nurses when there is no intent to harm a patient. He then looks at the system factors that may have contributed to the medication error, asking a number of questions about the circumstances under which Vaught made the error. The blog goes on to outline the serious impact the case could have on healthcare professionals' willingness to report errors, take on complex cases and use innovative treatments—it may even put people off taking on a career in the healthcare sector in the first place. -
Gallery Image
Bupivacaine alongside sodium choloride.jpg
Patient Safety Learning posted a gallery image in Medication
Bupivacaine solution, a medication used to decrease feeling in a specific area, alongside sodium chloride used as a saline solution. What could go wrong?! Another example of almost identical packaging/labelling. -
News Article
Drug shortages linked with medication errors, study results suggest
Patient Safety Learning posted a news article in News
A French study of adverse drug reactions has a highlighted a link between drug shortages and medication error. Data from the French Pharmacovigilance Database show that medication errors were identified in 11% of the 462 cases mentioning a drug shortage. The researchers found that medication errors usually occurred at the administration step and involved a human factor. “A drug shortage may lead to a replacement of the unavailable product by an alternative,” the researchers wrote. “However, this alternative may have different packaging, labelling, dosage and sometimes a different route of administration that may increase the risk of a medication error.” Read full story (paywalled) Source: The Pharmaceutical Journal, 11 October 2022 -
Content ArticleThis chapter from the book 'Managing future challenges for safety' starts with the premise that the future of work is unpredictable. This has been illustrated by the COVID-19 pandemic, and further profound changes in contexts of work will bring significant and volatile changes to future work, as well as health, safety, security, and productivity. Micronarrative testimony from healthcare practitioners whose work has been affected dramatically by the emergence of the pandemic is used in this chapter to derive learning from experience of this major change. The narratives concern the nature of responding to a rapidly changing world, work-as-imagined and work-as-done, human-centred design and systems thinking and practice, and leadership and social capital. Seven learning points were drawn from clinicians’ reflections that may be more widely relevant to the future of work.
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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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Content ArticleReliable patient identification is essential for safe care, but system factors such as working conditions, technology, organisational barriers and inadequate communications protocols can interfere with identification. This study in the Journal of Patient Safety aimed to explore systems factors contributing to patient identification errors during intrahospital transfers. The authors observed 60 patient transfer handovers and found that patient identification was not conducted correctly in any of them (according to the hospital policy at every step of the process). The principal system factor responsible was organisational failure, followed by technology and team culture issues. The authors highlight a disconnect between the policy and the reality of the workplace, which left staff and patients in the study vulnerable to the consequences of misidentification.
