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Showing results for tags 'Human factors'.
Found 552 results
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Content ArticleSafety in aviation and maritime domains has greatly improved over the years, but there is no room for complacency. This is especially the case as we approach systems with ever more automation and use of remote control in both industries. It is also more complicated because ‘human error’ is often seen as the root cause, when usually it is the system that leads people into mistakes, and seafarers and flight crew alike so often save the day. Accidents, incidents and near misses all offer us valuable lessons from which to improve safety, to do better next time. Yet in the aftermath of adverse events, the wish to blame someone, which makes sense of something that was never intended to happen, might make us lose sight of the real causes of accidents, leading to more tragedy and loss. The key to learning is using the right tool with which to understand what happened and why. This means going beyond the surface ‘facts’ and suppositions, seeing beneath the ‘usual suspects’ of factors that yield little in terms of how to prevent the next one. The SHIELD (Safety Human Incident & Error Learning Database) taxonomy has been developed by reviewing a number of existing taxonomies - in this case, a set of related terms for describing human performance and error - to derive a means of objectively classifying events in a way that helps us develop safety countermeasures afterwards. Whilst it can analyse single events it is particularly insightful when looking - and learning - across related events
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Content ArticleCommunity Diagnostic Centres (CDCs) can relieve pressure on NHS acute services and bring diagnostic services closer to patients. This resource by the Chartered Institute of Ergonomics & Human Factors (CIEHF) explores ten principles for including systems thinking in the design of the diagnostic workforce and CDC services.
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on risk and behaviour to improve patient safety. Key learning objectives: Evaluating risk Using mapping techniques Safety interventions Behaviour Assessing safety culture Register
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on non-technical skills to improve patient safety. Key learning objectives: Task analysis Cognitive overload Reliability Non-technical skills Examples Register
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus 2021. The new Patient Safety Strategy advises that organisations must adopt a new and broader approach to stimulate learning from patient safety incidents. This course is designed to assist healthcare professionals involved in this important work. The main purpose is to provide learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs). Traditionally, root cause analysis has been used as a blanket approach to diagnosing why patient safety have been compromised, but healthcare teams are henceforth being encouraged to adopt a wider range of methods that will both save time and facilitate enhanced learning. The focus is now on appropriate proportionality in response to incidents that occur in their organisation. Key learning objectives: Understand the new patient safety landscape. Understand the need for proportionality of investigation. Learn how to use a range of techniques for conducting PSIIs. Understand how to write an impactful improvement plan. Consider how your current approach to patient safety investigations compares to the agreed national standards. Understand typical pitfalls and traps associated with this wider workstream and tips for avoiding them. Register
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on errors and designing system-based solutions to improve patient safety. Key learning objectives: Understand what Human Factors are Learning from incidents Designing system-based solutions Preventing human error Blame and psychological safety Just culture Register
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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 -
Eventuntil“Getting the human factors right minimises error, and maximises performance. It makes it easier to do the right thing, and harder to do the wrong thing.” - Health Education England. Human Factors Training (HFT) has been endorsed by the NHS and embedded in Mandatory training in many hospitals throughout the UK. It aims to reduce errors and harm to patients by educating NHS staff on the factors that create unsafe environments . During the recent NOA webinar discussing Never Events and Serious Incidents, a poll of participants showed that 40% had none or little knowledge of Human Factors. For this webinar we welcome Fran Ives, Human Factors Specialist and the Human Factors team at the Robert Jones and Agnes Hunt Hospital (RJAH) where HFT has been established for all staff to discuss the principles and experience of the Trust. The RJAH team will give a brief overview of human factors and ergonomics, its relevance and role in improving patient safety, how it has been embedded at RJAH and the impact it has had. Fran will highlight her experience of the application of 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. Speakers include: Fran Ives, Chartered Human Factors Specialist, West Midlands Academic Health Science Network Dr Sophie Shapter, Consultant Anaesthetist & Lead for Human Factors and a Patient Safety Specialist, The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust Mr Simon Lewthwaite, Consultant Orthopaedic Surgeon, The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust Register for the webinar
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Content ArticleIn this analysis, published by the Human Factors and Ergonomics Society, the authors look at the impact of double checking medication to reduce errors and improve patient safety.
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EventSEIPS 2.0 is the most widely used model in human factors in healthcare. This one day masterclass will look at the model itself and how it can be applied to healthcare departments. It will look at real world examples as well as the literature. SEIPS 2.0 is the next-generation healthcare human factors model , which embraces 3 principles of Systems orientation, Person-centeredness and Design-driven improvement. Key learning objectives What is SEIPS 2.0? How does SEIPS link to Patient Safety? How to use SEIPS 2.0 clinically? • How to improve technology? Engaging patients and families Register hub members receive a 20% discount. Email info@pslhub.org
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Human Factors in your work and your team
Patient Safety Learning posted an event in Community Calendar
This virtual masterclass will guide you in how to use Human Factors in your workplace. All medical and non-medical staff should attend. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. It can be used to assess why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. The course is facilitated by Perbinder Grewal, a General & Vascular Surgeon, Human Factors & Patient Safety Trainer, and Emotional Intelligence Practitioner; leads on medical education both locally and nationally; Member of the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh; formerly lead for e-learning for healthcare for the Royal College of Surgeons of England; experienced trainer and coach who uses new insights to develop patient safety, staff engagement and psychological safety; has Postgraduate Certificates in Leadership and Coaching. Register hub members receive a 20% discount. Email info@pslhub.org for discount code. -
Content ArticleDuplicate medication orders are a prominent type of medication error that in some circumstances has increased after implementation of health information technology. Duplicate medication orders are commonly defined as two or more active orders for the same medication or medications within the same therapeutic class. While there have been several studies that have identified contributing factors and described potential solutions, duplicate medication order errors continue to impact patient safety.
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Content Article
Patient Safety Now: safety II and maternity (September 2022)
Patient-Safety-Learning posted an article in Maternity
Safety II moves away from simply looking at what went wrong, and aims to understand the realities of everyday work in a constructive and positive way. It focuses on the system as a whole, rather than the end result of the work done. In this blog, Professor Suzette Woodward, Professional and Clinical Advisor in Patient Safety, looks at the role of the Safety II approach in making maternity services safer. She outlines the importance of asking and listening to staff about how to reduce complexity and reform areas of the system that are prone to error. -
EventuntilThis webinar offers a chance to explore the challenges and opportunities of the Safety-II approach with Mark Sujan, co-author of the BMJ Quality and Safety article ‘The problem with making Safety-II work in healthcare.’ In 2020 Q’s ‘Organisational Resilience & Safety-II’ Special Interest Group (SIG) ran workshops to share adaptations being made to address the emerging COVID-19 crisis. Many solutions were shared but significant challenges were identified. In this webinar we will build on the insights found and explore the arguments in the recent BMJ Quality and Safety article, ‘The problem with making Safety-II work in healthcare.’ We will be joined by the paper’s co-author Mark Sujan, as we lean into the promises and potential of Safety-II, and what gaps we need to bridge to revolutionise our understanding of what safety truly is in health care. The one hour webinar will: Outline the challenges and opportunities of a Safety-II approach Allow you to hear from peers implementing Safety-II Provide you with an opportunity to discuss your experiences of Safety-II in small groups Register for the webinar
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Content ArticleSerious incident (SI) investigations aim to identify factors that caused or could have caused serious patient harm. This study from Mary Dixon-Woods and colleagues aimed to use the Human Factors Analysis Classification System (HFACS) to characterise the contributory factors identified in SI investigation reports.
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Just Culture and incident investigation
Patient Safety Learning posted an event in Community Calendar
untilThis virtual seminar from the Clinical Human Factors Group will be looking at Just Culture and incident investigation and will feature two of the authors, Jan Davies and Carmella Steinke, of the new book 'Fatal Solution' , a book which describes "how a healthcare system used tragedy to transform itself and redefine Just Culture". In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture." To accompany this story Ken Catchpole, Professor of Human Factors at Medical University of South Carolina will discuss a variety of enablers and barriers to learning from clinical safety incidents, based on his perspective within the US health system. This will illustrate the format of incident analysis and response at MUSC; legal and regulatory issues; and the role and impact of human factors and systems engineering. He will also comment on the recent RaDonda Vaught case, and what that tells us about how far we still have to go. Jane O’Hara, Professor of Healthcare Quality and Safety in Leeds will adds a UK perspective to this worldwide issue, together with a session focusing on the view from a pharmacy perspective. Register- Posted
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Content ArticleMore work is needed on understanding and addressing a lack of sleep in rail workers, a new study has argued. Researchers looked at the difference between when staff were on day shifts and when they were working at night. They discovered a “feast and famine” scenario where 41% reported getting six hours of sleep or less when working days, compared to 63% when working nights. The findings, published in the Applied Ergonomics journal, suggested that many staff weren’t getting enough sleep and having less than six hours was linked to feeling very sleepy during the day. More than one in ten shift workers also reported they had been awake for between 18 and 24 hours by the time they finished work at least once during the past week. This led to fears that their tiredness could have an impact on road safety if they were driving home from work. The report said: “Sleep restriction and sleep deprivation, even in the short term, are known to affect cognitive performance. For a safety critical industry, this data should raise a significant concern.”
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Content ArticleThis worksheet produced by NHS Education for Scotland is designed to be used by healthcare teams as a prompt to highlight the various system-wide factors that contribute to an issue. It aims to help teams understand how these factors relate and interact to produce different outcomes.
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EventuntilWhat we’re getting wrong about the “Five rights of medication use” and other safety myths Despite decades of focus, medication errors, which result from weak medication systems and human factors, constitute the greatest proportion of total preventable harm. Yet across decades of efforts to improve medication safety, a disproportionate burden continues to be placed on human performance, while examination and focus on improving systems and the cultures in which humans work is often limited and reactive. In recognition of World Patient Safety Day, this free Institute for Healthcare Improvement (IHI) webinar examines how traditional approaches to medication safety continue to impede progress. Interprofessional faculty with expertise in systems thinking and human factors engineering will share insights on reorienting our thinking and approaches to medication safety. This webinar will provide fresh ideas for engaging a cross-disciplinary, systems perspective and harnessing team members in the improvement of systems to support medication safety. What you'll learn Review commonly held myths about humans that limit progress in medication safety, including the “Five Rights of Medication Use.” Discuss how human factors design and interventions support human performance and improvements in medication safety. Identify at least one idea for change that you can consider for improving medication safety in your organization. Register This webinar will take place at 12:00-13:00 ET (17:00-18:00 BST)
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Content ArticleEverybody makes mistakes at work but what if you're a doctor and you ruin a patient's life - or even end it? Doctor-turned-writer Jed Mercurio recalls a catalogue of errors from his years as a medical student.
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Content ArticleBrian Edwards, Managing Director of Husoteria Ltd, shares his speaker abstract from the 5th European pharmacovigilance congress held 1-3 December 2021. To view all the speaker abstracts from the congress, published in the Therapeutics Advances in Drug Safety journal, download the attachment below.
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EventuntilThis two day masterclass will start by providing learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs) followed by how to use Human Factors in your workplace. All medical and non-medical staff should attend. For further information and to book your place visit www.healthcareconferencesuk.co.uk/virtual-online-courses/human-factors-safety-investigations or email kerry@hc-uk.org.uk hub members receive 20% discount. Email info@pslhub.org for discount code.
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EventAimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process and safety. There will be an extended focus on the role of human factors in patient safety investigation in line with the new National Patient Safety Incident Response Framework (PSIRF). For further information and to book your place visit www.healthcareconferencesuk.co.uk/conferences-masterclasses/human-factors-in-healthcare or email aman@hc-uk.org.uk Follow on Twitter @HCUK_Clare #HumanFactors hub members receive 20% discount. Email info@pslhub.org for discount code.
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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. We 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. For further information and to book your place visit www.healthcareconferencesuk.co.uk/conferences-masterclasses/red-teams-patient-safety or email kerry@hc-uk.org.uk hub members can receive a 20% discount. Email info@pslhub.org for discount code. -
Content Article
Advancing Quality Alliance: Safety Culture Survey
Patient Safety Learning posted an article in Culture
This programme from the Advancing Quality Alliance (Aqua) provides participants with the tools, skills and knowledge to oversee the successful implementation of a safety culture survey in organisations. Participants of this programme will develop a working knowledge of safety culture theory and the Agency for Healthcare Research and Quality (AHRQ) safety culture survey alongside the support that Aqua provides to enable deployment and analysis of the survey. This programme links directly to Aqua’ safety offers, including Psychological Safety, Human Factors and Improvement Practitioner programmes.
