Search the hub
Showing results for tags 'Human factors'.
Found 552 results
-
Event
Aiming for zero patient safety incidents or errors
Sam posted an event in Community Calendar
This virtual masterclass, facilitated by Mr Perbinder Grewal, will focus on patient safety and how to setup a proactive safety culture. It will look at what patient safety is and how to setup and improve the safety culture. It will look at Human Factors and how to mitigate some of the common errors. Can we have a system with zero patient safety incidents or errors? Further information and book your place or email kate@hc-uk.org.uk hub members receive 10% discount. Email info@pslhub.org for code -
Content ArticleThe Great Ormond Street Hospital for Children is one of London’s most respected health care institutions. Despite their long history of success, hospital leaders wanted to explore new ways to improve patient safety and decrease medical errors. In their efforts to deliver the best possible outcomes, they turned to a surprising source of inspiration. It turns out that many health care errors occur during transitions, such as transporting a patient into surgery. In rapidly changing, high-stakes moments, split-second errors can lead to disastrous outcomes. Instead of studying other hospitals, the leaders at Great Ormond Street turned to Ferrari’s Formula One pit crew team.
-
Event
ASiT Christmas Human Factors Webinar
Sam posted an event in Community Calendar
He's making a list, he's checking it twice... Santa Claus definitely understands the importance of human factors - how else could he be so efficient in just 24 hours..? Join the Association of Surgeons in Training on 22nd December for a festive human factors webinar, featuring Prof Peter Brennan and Critical Factors. (Read Peter's recent blog for the BMJ's Christmas feature.) Free to attend, and open to the whole healthcare team. Register -
Content ArticleDuring the festive period, Father Christmas has the busiest 24 hours of his year delivering Christmas presents across the world. While this seems an insurmountable task, for him it’s all in a night’s work, facilitated by applying human factors (HF) in many areas. However, as with healthcare, there is always room for reflection, learning and improvement for the benefit of consumers... Feature from Peter A Brennan and Rachel S Oeppen in the BMJ's Christmas 2020: Dr Strange.
-
Content Article
Why investigate? Part 7 – The questions and answers
MartinL posted an article in Why investigate? Blog series
In part 1 of my blog series, I said "This will be a series of short blogs that will cover the investigation process, answer questions about humans, and shine a light on the method of forensic investigations”. It is time to answer some questions -
Content ArticleSupport in clinical decision making is recognised as an educational development need for pharmacists. The health policy landscape puts the pharmacist in a central role for clinical management of long-term complex morbidities, making clinical decision making and taking responsibility for patient outcomes increasingly important. This is compounded by the COVID-19 pandemic, where healthcare environments have become more complex and challenging to navigate. In this environment, foundation pharmacists were unable to sit the GPhC registration assessment during the summer of 2020 but provisionally the registration assessment is due to take place online during the first quarter of 2021. In response to this, a suite of resources has been developed with collaboration between Chartered Institute of Ergonomics and Human Factors (CIEHF) and Health Education England (HEE). These resources are aimed in particular at early career pharmacists and their supervisors, especially those in foundation pharmacist positions managing the transition from education to the workplace environment.
-
Content ArticleOrganisations expect to see consistency in the decisions of their employees, but humans are unreliable. Judgments can vary a great deal from one individual to the next, even when people are in the same role and supposedly following the same guidelines. And irrelevant factors, such as mood and the weather, can change one person’s decisions from occasion to occasion. This chance variability of decisions is called noise, and it is surprisingly costly to companies, which are usually completely unaware of it.
-
Content ArticleThis guidance from the Chartered Institute of Ergonomics and Human Factors (CIEHF) is aimed at early career pharmacists, especially those in foundation pharmacist positions managing the transition from education to the workplace environment. Support in clinical decision-making is recognised as an educational development need for early career pharmacists, making the transition from a university education where there is very little exposure to the clinical environment into the work environment. This situation is compounded by a policy landscape which puts the pharmacist in a central role for clinical management of long-term complex morbidities, making clinical decision making and taking responsibility for patient outcomes increasingly important. The guidance will also be of use to those involved in the education and mentorship of early career pharmacist.
-
Content ArticleIn this review, Jane Carthey and colleagues discuss human factors research in cardiac surgery and other medical domains. The authors describe a systems approach to understanding human factors in cardiac surgery and summarise the lessons that have been learned about critical incident and near-miss reporting in other high technology industries that are pertinent to this field.
-
Content Article
Keeping staff safe during COVID-19: Risk assessments
PatientSafetyLearning Team posted an article in Staff safety
Staff safety is fundamental to running an effective health service and delivering quality care. This year has highlighted how important risk assessments are in protecting the NHS workforce, as it continues to respond to the COVID-19 pandemic. We know that frontline healthcare staff are more at risk of becoming infected with COVID-19. We also know the virus has a disproportionate impact on staff from minority ethnic communities, and that many NHS workers are considered “clinically vulnerable” to COVID-19. There are also risk factors that relate to gender, age, weight and many more. This can understandably leave staff feeling confused about what they should and shouldn’t be doing to look after themselves and their colleagues. On 24 June, it became mandatory for all trusts to complete occupational risk assessments of vulnerable NHS workers. In this interview, Patient Safety Learning speaks to James Duez, CEO of Rainbird. James tells us how his company developed an automated decision-making tool, able to produce individualised risk assessments so that appropriate measures can be put in place quickly. -
Content Article
Error traps: Let’s raise awareness
Patient Safety Learning posted an article in Error traps
An error trap is a situation that could lead into avoidable harm if not mitigated. It is a situation where the circumstances in combination with human cognitive limitations make errors more likely.[1] Error traps can be found throughout health and social care in medicines, equipment and devices, in documentation, and in many other areas we see every day while going about our daily jobs in health and social care. We want to raise awareness of these error traps on the hub but more importantly we want to hear your suggestions of what needs to be done to prevent them and examples of where action has been take and worked. View our error trap gallery and share your examples.- Posted
- 7 comments
-
4
-
- (and 3 more)
-
Event
Using human factors to support clinical decision making
Sam posted an event in Community Calendar
untilCoping with complexity: how a human factors systems approach can support competency development for pharmacists. Support in clinical decision making is recognised as an educational development need for pharmacists. The health policy landscape puts the pharmacist in a central role for clinical management of long-term complex morbidities, making clinical decision making and taking responsibility for patient outcomes increasingly important. This is compounded by the COVID-19 pandemic, where healthcare environments have become more complex and challenging to navigate. In this environment, foundation pharmacists were unable to sit the GPhC registration assessment during the summer of 2020 but provisionally the registration assessment is due to take place online during the first quarter of 2021. In response to this, a suite of resources has been developed with collaboration between Chartered Institute of Ergonomics and Human Factors (CIEHF) and Health Education England (HEE). These resources are aimed in particular at early career pharmacists and their supervisors, especially those in foundation pharmacist positions managing the transition from education to the workplace environment. This session will act as the launch event for these resources and can support early career pharmacists and supervisors to navigate the CIEHF learning resources developed so far. Register -
Content ArticleDebriefs (or After Action Reviews) are increasingly used in training and work environments as a means of learning from experience. Tannenbaum and Cerasoli assessed the efficacy of debriefs with a quantitative review and found organisations can improve individual and team performance by approximately 20% to 25% by using properly conducted debriefs.
-
Content Article
Flight Safety Foundation: Just Culture Manifesto
Patient Safety Learning posted an article in Culture
“Just Culture” is a culture in which front-line operators and others are not punished for actions, omissions or decisions taken by them which are commensurate with their experience and training, but where gross negligence, wilful violations and destructive acts are not tolerated. Organisations are run by people. In tens of industries – transportation, healthcare, energy, internet, and more – thousands of occupations, and millions of organisations around the world, it is people who make sure that things normally go well. And they nearly always do. But sometimes, things go wrong. Despite our best efforts, incidents, accidents and other unwanted events happen. Following such events, there is a need for support and fairness for those involved and affected, and learning for organisations, industry and society as whole. In the absence of intentional wrongdoing or gross negligence, these obligations should not be threatened by adverse responses either by organisations or States. The Flight Safety Foundation outline their Just Culture Manifesto and invite all who support the principles in this Manifesto to join them, and to help make Just Culture a reality in all countries, industries, and occupations. -
Content ArticleAnnie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without a blame and shame approach.
-
Event
Ergonomics and Human Factors 2021
Patient Safety Learning posted an event in Community Calendar
untilWhether you’re an industry or business leader, a human factors practitioner, researcher or academic, the Chartered Institute of Ergonomics & Human Factors showcase the very best that the discipline has to offer at one of the largest gatherings of ergonomists and human factors professionals in the world. Further information and registration -
Content ArticlePresentation from Paul Bowie, Programme Director, NHS Education for Scotland on human factors and ergonomics.
-
Content ArticleUsing a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia. Patel et al., following a near-miss and subsequent educational and training efforts at their institution, they conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient’s refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination. They found only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique. Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.
-
Content ArticleIt's important to think about how we are safe on the front line, doing the work day in and day out. How do our policies, processes and practices across an entire organisation impact the safety of our work? Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. He currently specialises as a human factors and safety specialist in air traffic control in Europe, but has worked across most safety critical sectors. In this podcast, from the East of England Ambulance Service (EEAST) General Broadcast, Steven talks about how policies can interfere with each other, how hierarchy impacts performance and reflects on incidents.
-
Content ArticleIn 2002 the UK Department of Health and the Design Council jointly commissioned a scoping study to deliver ideas and practical recommendations for a design approach to reduce the risk of medical error and improve patient safety across the National Health Service (NHS). The research was undertaken by the Engineering Design Centre at the University of Cambridge, the Robens Institute for Health Ergonomics at the University of Surrey and the Helen Hamlyn Research Centre at the Royal College of Art. The research team employed diverse methods to gather evidence from literature, key stakeholders, and experts from within healthcare and other safety-critical industries in order to ascertain how the design of systems—equipment and other physical artefacts, working practices and information—could contribute to patient safety. Despite the multiplicity of activities and methodologies employed, what emerged from the research was a very consistent picture. This convergence pointed to the need to better understand the healthcare system, including the users of that system, as the context into which specific design solutions must be delivered. Without that broader understanding there can be no certainty that any single design will contribute to reducing medical error and the consequential cost thereof.
-
Content ArticleOne of the areas where Human Factors is getting more traction is within the healthcare sector. It is still a slow burner though with lots more work to be done, and this is getting more urgent as new technologies are available to make procedures and processes better and potentially support more effective patient outcomes. Dr Mark Sujan has taken this challenge head on by launching the Artificial Intelligence and Digital Health Special Interest Group with the CIEHF. In this podcast, we find out more about Mark and his motivations, as well as what his intentions for the Special Interest Group are.
-
Content ArticleIn his latest blog, Steven Shorrock explores what humanistic values and human decency means in management and organisational behaviour. Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives.
-
Content ArticleOptimising patient safety is a goal of healthcare. Much has been spoken and written about it, and it is well established as a core activity for all those working in healthcare systems. This has not always been the case; historically, error and harm from healthcare was an accepted risk of treatment. However, as standards of treatment and care have improved this acceptability was questioned and refuted, and the patient safety movement born. This article, published in Anaesthesia, summarises the evolution of safety science, describing historical approaches, comparing them with recent concepts in safety, and describing how they affect staff working within the healthcare system.
-
Content ArticleSusan Warby, 57, was mistakenly given a glucose rather than a saline drip at West Suffolk Hospital after an operation for a perforated bowel in July 2018. Staff noticed a rise in blood sugar concentrations but gave her insulin to lower them rather than check the drip, which remained in place for 36 hours. In 2008 the National Patient Safety Agency made recommendations for safe arterial line management. In 2014 the Association of Anaesthetists published guidelines aimed specifically at preventing such events. Structured processes to prevent inadvertent use of a glucose-containing fluid to flush an arterial line and regular blood glucose sampling from a location other than the arterial line are only partial solutions. However, a survey of management of arterial lines undertaken in 2013 indicated that this was a common problem, that many of the NPSA recommendations were not widely implemented and that almost one third of respondents were aware of ‘wrong flush’ errors on their unit and a further third in other locations within their hospital. In this Rapid Response in the BMJ, Tim Cook says now is the time for patient representatives, clinicians, regulators and industry to work together to achieve widespread implementation of an engineered solution to prevent arterial line errors.
-
Content Article
CIEHF: COVID-19 human factor response
Patient Safety Learning posted an article in Guidance
The pandemic has brought human factors issues to prominence. The Chartered Institute of Ergonomics and Human Factors (CIEHF) and its members are responding rapidly to current challenges by providing expert guidance and help wherever it’s needed most. This site gives details and links to new guidance documents developed and published by us and matches human factors expertise to those needing assistance.
