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Showing results for tags 'Human factors'.
Found 547 results
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Content ArticleWe are delighted to announce that Patient Safety Learning has been recognised amongst the finalists at this year’s Chartered Institute of Ergonomics and Human Factors (CIEHF) Professional Awards 2021.
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Content ArticleMedicine has traditionally been one of the most cognitively demanding occupations. This paper from Bob Baron, President and Chief Consultant of The Aviation Consulting Group, discusses the limitations of human performance in the hospital environment. Human factors models are presented and used as an anchor for a randomly selected case study involving a potentially lethal medication error. The case study’s root cause analysis showed five distinct factors that were causal to the error. The human factors models, in conjunction with an overview of basic human cognition, provide the reader with the tools to understand all five findings of the case study. This paper will provide a foundation for improving medical safety by creating an awareness of the factors that influence errors in medical procedures.
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Content ArticleSue Hignett and Paul Bowie propose taking a much-needed professional approach to patient safety through an accredited learning pathway to integrate safety into clinical systems and develop healthcare safety specialists and experts
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Content ArticleResilient Healthcare is an emerging theoretical field that has developed with influence from engineering, safety science, psychology, ergonomics, human factors, and aeronautics. Resilient Healthcare research has centred on understanding and improving the quality and safety of healthcare delivery. Theory is increasingly well-developed, but so far has only been applied in limited ways with select settings and activities. In order to improve the quality and safety of healthcare, it is essential to first understand the sources of complexity in clinical work. This ethnographic study from Sanford et al. of five hospital teams in a large, teaching hospital in central London aims to contribute to this growing evidence base by presenting data on specific challenges faced by healthcare workers and the adaptations they use to overcome them in everyday clinical work. This paper will present a new framework for recognising misalignments between demand and capacity and corresponding mechanisms for adaptation, which can be used to understand work-as-done in complex settings and to manage risk.
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Content ArticleIn this article, published in Human Factors and Ergonomics in Manufacturing & Service Industries, the authors present a model for integrating Human Factors/Ergonomics (HFE) into healthcare systems to make them more robust and resilient. They believe that to increase the impact of HFE during and after the Covid-19 pandemic this integration should be carried out simultaneously at all levels (micro, meso, and macro) of the healthcare system. This new model recognises the interrelationship between HFE and other system characteristics such as capacity, coverage, robustness, integrity, and resilience.
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Content ArticleThis study in Anaesthesia reviewed accidental spinal administration of tranexamic acid. The review identified 20 cases of accidental administration resulting in life-threatening neurological or cardiac complications and 10 patient deaths. These cases were analysed using a Human Factors Analysis System Classification model to identify contributing factors. Ampoule error was the cause in 20 incidents, and all were classified as skills-based errors. Organisational policy, storage of medication and preparation for anaesthesia were all identified as contributing factors. The authors concluded that all of these events could have been avoided if four published recommendations for the prevention of spinal medication administration were implemented.
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Content ArticleWhen students enter medical school or junior doctors start specialist training, they don’t aim to be a “good enough” doctor—they want to be the best. However, we make mistakes or a patient has complained. It’s likely that someone picked up the error and no harm resulted, and the complaint may not be deserved—but still it punctures your pride and reminds you that you’re not perfect. It may even make you question whether you’re good enough. None of us is perfect, and self-criticism can wear us down or burn us out. Helen Salisbury in this BMJ article, suggests however, that in the long term we’re of more use to the world if we can live with our errors, share them, and learn from them. Our patients would prefer that we never made any, but they accept that we’re human and fallible. Learning to admit those errors to patients, and to say sorry, is one of the hardest but most important steps to becoming a good enough doctor.
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Content ArticleIn July 2017, the Royal College of Surgeons of Edinburgh published a number of critical recommendations to government to greatly improve safety in the delivery of surgical treatment and patient care, with seven recommendations for best practice. The RCSEd surveyed opinions from a cross-section of the UK surgical workforce - from trainees to consultants - which highlighted broad inefficiencies on the frontline which impact the working environment and the delivery of a safe service. The report notes factors adversely affecting morale, including a lack of team structure, poor communication, high stress levels, and limited training opportunities. The report also records how staff, at times, feel diverted away from the patient-centred care they strive to deliver because of administrative and IT issues, and believe that being more innovative and efficient with existing resources could make a positive difference.
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Content ArticleThis study in The Journal of Minimally Invasive Gynecology applied a structured human factors analysis to understand the factors that contribute to vaginal retained foreign objects (RFOs). Trained human factors researchers looked at 45 incidents that occurred between January 2000 and May 2019 at an academic medical centre in Sothern California. The narrative of each incident was reviewed to identify contributing factors, classified using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare). The authors of the study concluded that the top two contributing factors in vaginal RFO incidents were skill-based errors and communication breakdowns. Both types of errors can be addressed and improved with human factors interventions, including simulation, teamwork training, and streamlining workflow to reduce the opportunity for errors.
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Content ArticlePatients are increasingly encouraged to be active participants in managing their own health. New technologies, cultural shifts, trends in healthcare delivery and policies have brought the patients’ role in healthcare to the forefront. This session from the Chartered Institute of Ergonomics and Human Factors (CIEHF) reviews and advances the emerging discipline of Patient Ergonomics. It focuses on patients and their performance. It presents practical recommendations and case studies useful for researchers and practitioners and covers diverse healthcare settings outside hospitals and clinics, providing a combination of foundational content and specific applications.
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Content ArticleThe Chartered Institute of Ergonomics and Human Factors (CIEHF) has launched an oxygen safety campaign aimed at people working at patient bedsides within hospitals. They have consulted with clinicians, fire safety experts and a wide range of allied professional bodies to design the campaign, which has been launched in response to the anticipated national surge in hospital patients as a result of the Omicron variant. Inevitably, the use of oxygen will be very high and issues such as oxygen leakage can cause major fire risks.
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Content ArticleA shared lingo can create cohesion in “the unit,” but James M Hodgetts and colleagues ask whether this is exclusionary and puts patient safety at risk. They collected the slang terms used by others and ourselves in the intensive care unit (ICU) over six months and collated these terms and expressions (those that can be committed to print) in a mini-dictionary of ICU slang, and some are used in UK medicine more broadly. They hope that the dictionary may be of use and possibly a source of amusement—and that it causes ICU staff and other healthcare workers to reflect on the suitability and inclusivity of the language they use with colleagues.
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Content ArticleHuman factors and ergonomics (HF/E) is concerned with the design of work and work systems. There is an increasing appreciation of the value that HF/E can bring to enhancing the quality and safety of care, but the professionalisation of HF/E in healthcare is still in its infancy. In this paper, Sujan et al. set out a vision for HF/E in healthcare based on the work of the Chartered Institute of Ergonomics and Human Factors (CIEHF), which is the professional body for HF/E in the UK. The authors consider the contribution of HF/E in design, in digital transformation, in organisational learning and during COVID-19.
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Content Article
Vaccinating a Nation: Lessons from Scotland (CIEHF)
Patient Safety Learning posted an article in Guidance
This is the Chartered Institute of Ergonomics and Human Factors (CIEHF)'s second guide in response to issues concerning vaccination and COVID-19. It documents the key learnings gained from the human factors assessment of the vaccination system implemented by NHS Ayrshire & Arran (NHSAA). Its purpose is to share success, recommend design and safety improvements and offer a universal template for future safe and effective rollouts of time-critical vaccination programmes. The guidance will also be useful for the design and delivery of any public health vaccination programmes post COVID-19. Further reading CIEHF: COVID-19 human factor response -
Content ArticleTechnical developments tend to grab the headlines in health care. Predictive analytics, telemedicine, electronic health records — technology is rightly seen as a transformative force in health delivery. But it’s not the only one. At Rotterdam Eye Hospital, hospital administrators have found that through their ongoing design-thinking programme, lower-tech measures can also improve health care. Simple measures such as building a more intuitive website, replacing harsh fluorescent lighting and cold linoleum floors with softer lighting and wood parquet, and giving children and pediatric ophthalmologists matching T-shirts have reduced patient fears. Addressing patients’ fears is important because fear can make an eye operation difficult or even impossible. Moreover, less fear translates into greater patient satisfaction. In an article for Harvard Business Review, Dirk Deichmann and Roel van der Heijde explain how now Rotterdam Eye Hospital has integrated a measure that is even lower-tech: better conversations...
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Content ArticleThe Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models provide a framework for integrating Human Factors and Ergonomics (HFE) in health care quality and patient safety improvement. As care becomes increasingly distributed over space and time, the “process” component of the SEIPS model needs to evolve and represent this additional complexity. In this paper, Carayon et al. review different ways that the process component of the SEIPS models have been described and applied. Carayon et al. propose the SEIPS 3.0 model, which expands the process component, using the concept of the patient journey to describe the spatio-temporal distribution of patients’ interactions with multiple care settings over time. This new SEIPS 3.0 sociotechnical systems approach to the patient journey and patient safety poses several conceptual and methodological challenges to HFE researchers and professionals, including the need to consider multiple perspectives, issues with genuine participation, and HFE work at the boundaries.
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Content ArticleIn North America, although pharmacists are obligated to ensure prescribed medications are appropriate, information about a patient’s reason for use is not a required component of a legal prescription. The benefits of prescribers including the reason for use on prescriptions is evident in the current literature. However, it is not standard practice to share this information with pharmacists.The aim of this study was to characterise the research on how including the reason for use on a prescription impacts pharmacists.The results suggest that including the reason for use on a prescription can help the pharmacist catch more errors, reduce the need to contact prescribers, support patient counseling, impact communication, and improve patient safety. Reasons that may prevent prescribers from adding the reason for use information are concerns about workflow and patient privacy.
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Content ArticleThis briefing by NHS Supply Chain looks at shared learning on patient safety, and how collaborative working is enabling better assurance and safety for healthcare products and services. The briefing covers these topics: The role of NHS Supply Chain in patient safety Safety specifications for safer products System-level join up Human factors and just culture Case studies Overview of system partners Conclusion
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Content ArticleIn this blog, a patient who experienced life-changing surgical complications describes the process of reconciliation between medical staff and patients when harm has occurred in healthcare. She highlights the need for both the patient and healthcare professional to be engaged and open in the process. She also looks at how different human factors can negatively impact on the duty of candour process, and why they need to be acknowledged. These factors include lack of communication, distraction, lack of resources, stress, complacency, lack of teamwork, pressure, lack of awareness, lack of knowledge, fatigue, lack of assertiveness and norms.
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Content Article'The Theatre: Surgical Learning & Innovation Podcast' is a podcast by the Royal College of Surgeons of England. This episode features a panel discussion on the nature of “human factors” in surgery, presented by Peter Brennan, consultant oral and maxillofacial surgeon, Louise Cousins, trainee general surgeon, Neil Tayler, British Airways pilot and trainer, and Graham Shaw, also a British Airways pilot and Director of Critical Factors, a consulting and training service for professionals operating in safety-critical environments.
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Content ArticleThis article, published in the American Journal of Medical Quality, examines pragmatic applications of simulation and human factors to support the Quadruple Aim of health system performance during the Covid-19 era.
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Event
SEIPS in radiology
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in radiology. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
Event
SEIPS masterclass in healthcare
Sam posted an event in Community Calendar
The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in healthcare. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Morning session: 9.30-12.30 Afternoon session: 1.30-4.30 Register -
Event
SEIPS in emergency department
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in Emergency Departments. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register -
Event
SEIPS in social care
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in Social Care. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Register
