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Showing results for tags 'Human factors'.
Found 549 results
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Content ArticleOne box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable – does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? 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.
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Content ArticleThe Guidance for Human Factors Evaluations in the Procurement of Medical Devices, Equipment and Technology document provides comprehensive recommendations on how one may integrate human factors evaluations into procurement processes. While it is a relatively new aspect to consider in healthcare supply management, and may entail robust change management to implement, incorporating human factors evaluation in purchasing will enable best value and outcomes in health care.
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Content ArticleThis article in the journal Trends in Neurology & Men's Health provides an outline of the role of human factors in preventing harm in healthcare. The authors describe the scale of medical errors and look at some specific ways that changes to personal and team working factors can improve safety for staff and patients.
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Content ArticleThe Safety Engineering Initiative for Patient Safety (SEIPS) is arguably the best known and most published systems-based Human Factors framework in healthcare worldwide. Developed by Professor Pascale Carayon and colleagues in the University of Wisconsin, the SEIPS framework is partly based on Donabedian’s well-known Structure-Process-Outcome model of healthcare quality. SEIPS is strongly grounded in a Human Factors based systems approach.
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Content ArticleAs a team, this worksheet can be used as a prompt to highlight the various system-wide factors that contribute to the issue at hand (e.g. implementing a new way of working; managing change or learning from a safety incident); seek to understand how these factors relate and interact to produce outcomes (desirable or undesirable).
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Content ArticleInsight into medical device and system failure and the teachings of Henry Petroski, a professor of civil engineering at Duke University, who wrote about failure analysis and design theory.
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AHRQ course- TeamSTEPPS® for diagnosis improvement
Patient-Safety-Learning posted an article in Diagnosis
Diagnostic harm is an area of concern in healthcare quality and patient safety. A growing body of patient safety and care delivery research shows that diagnostic harm is both widespread and costly. TeamSTEPPS is an evidence-based program built on a framework composed of four teachable, learnable skills—communication, leadership, situation monitoring and mutual support. The TeamSTEPPS for Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error. On the course. teams will learn about how improved communication among all members of the team can help lead to safer, more accurate and more timely diagnosis in all healthcare settings. The course can be delivered virtually, in a classroom setting or as individual self-paced learning modules. Additional resources for trainees include: Team assessment tool for improving diagnosis Case study of the diagnostic journey of Mr. Kane Reflective practice tool Postcourse knowledge assessment -
Content ArticleHealth systems currently present a great degree of complexity, which provides risks to patients related to healthcare, and the possibility of incidents with or without harm. Patient safety culture highlights the need to investigate, analyse, and mitigate incidents to reduce risks to the patient. Medication errors have a high potential to do harm in paediatric hospital routines and most of them are preventable. The objective of this study was to describe a severe drug-related adverse event and present the root cause analysis and implemented improvements.
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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. -
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 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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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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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 ArticleIn this paper, Kurtz and Snowden challenge the universality of three basic assumptions prevalent in organisational decision support and strategy: assumptions of order, of rational choice, and of intent. They describe the Cynefin framework, a sense-making device they have developed to help people make sense of the complexities made visible by the relaxation of these assumptions. The Cynefin framework is derived from several years of action research into the use of narrative and complexity theory in organisational knowledge exchange, decision-making, strategy, and policy-making. The framework is explained, its conceptual underpinnings are outlined, and its use in group sense-making and discourse is described. Finally, the consequences of relaxing the three basic assumptions, using the Cynefin framework as a mechanism, are considered.
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Content ArticleThis literature review in The Operating Theatre Journal examines why the decision was made not to class surgical fires as a 'Never Event', even though research has identified them as a preventable hazard. The author also examines steps that could be taken to further reduce the risk of surgical fires in the NHS and other health systems. You will need to create a free online account to view this article.
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This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on 26 August 2022. The discussion considered the use of two different system-based approaches for learning from patient safety incidents recommended by the NHS Patient Safety Incident Response Framework (PSIRF). The PSMN is an informal voluntary network for patient safety managers. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance, offer peer support and create a safe space for discussion. You can find out more about the network here -
Content ArticleAcross multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.
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Content ArticleProgress enables the creation of more automated and intelligent machines with increasing abilities that open up new roles between humans and machines. Only with a proper design for the resulting cooperative human–machine systems, these advances will make our lives easier, safer and enjoyable rather than harder and miserable. Starting from examples of natural cooperative systems, the paper from Flemisch et al. investigates four cornerstone concepts for the design of such systems: ability, authority, control and responsibility, as well as their relationship to each other and to concepts like levels of automation and autonomy.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to the use of a flush fluid and blood sampling from an arterial line in people who are critically ill in hospital. As its ‘reference case’, the investigation uses the experience of Keith, a 66 year old man who during a stay in a clinical care unit had blood samples taken from an arterial line which were contaminated with the flush fluid containing glucose. As a result he received incorrect treatment which led to his blood glucose levels being reduced to below the recommended limit.
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Content ArticleThis download is the first 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 ArticleProfessor Peter Brennan is a NHS Consultant Surgeon in Portsmouth, specialising in head and neck cancer. In this episode of the Human Factor Podcast, Peter discusses how he is driving Human Factors approaches from his perspective. To date, Peter has published over 700 publications including more than 80 on Human Factors and patient safety. His HF work has changed the delivery of postgraduate surgery exam delivery in the UK and abroad. Watch all the Human Factors Podcast episodes here.
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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 ArticleOver the few years, the Royal Air Force (RAF) has been going through a cultural evolution. In this episode of the Human Factors podcast, Ian James and Avril Webb give an insight into how the implementation of Human Factors and attitudes to safety have evolved in the RAF, and the positive impact this has had on the organisation.
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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. Jordan talks to us about his journey from drama school to patient safety, how the new Patient Safety Incident Response Framework (PSIRF) will change the way the NHS looks at safety, and how his love of driving makes him think differently about his role. A transcript of the interview is also available below.- Posted
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Content ArticleEngaging with company executives over how their decisions affect employees’ performance further down the line could help improve safety at sea. An 18-month study found investigations of maritime accidents tend to “blame the ship”, often resulting in the punishment of seafarers. Authors Barry Kirwan, Ben Wood and Beatrice Bettignies-Thiebaux of Eurocontrol, argue that this approach hampers learning and more attention needs to be paid to contributory factors from higher up the chain. They say that a deeper understanding of organisational influences and how company culture contributes to accidents will help promote safety across the business and better address problems. They have developed a ‘Reverse Swiss Cheese Maritime Model’ which moves from organisation through design and fleet support to vessel operations. To facilitate this, they believe there needs to be greater engagement between analysts and the industry’s decision makers and are hoping to trial their approach with several organisations over the next year. Barry, who presented the findings at our recent conference, said: “We need to look not only at how ‘work is done’ but how ‘business is done’.”
