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Showing results for tags 'Human factors'.
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Content Article
Patient referrals and waiting lists: A ticking time bomb
Jerome P posted an article in By health and care staff
Jerome, a patient safety manager, discusses the impact the pandemic is having on patient referrals and waiting lists, and the subsequent increases in serious incidents and never events that will arise. With an already overstretched and exhausted workforce, how will these be investigated, how will this be managed? Jerome urges NHS England to give guidance.- Posted
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Content ArticleIn Part 8 of the 'Why investigate' blog series, Martin Langham takes a look at the hub's error trap gallery and explains why when we conclude it's an error trap we are missing the bigger picture.
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Content ArticleThe COVID-19 pandemic has exacerbated preexisting weaknesses in the global supply chain. Regional assessments by the Food and Drug Administration (FDA), European Medicines Agency (EMA), and independent consultants, have demonstrated various contributory causal factors requiring changes in policy, relationships, and incentives within the dynamic and developing networks. Human factors and ergonomics (HFE) is an approach that encourages sociotechnical systems thinking to optimize the performance of systems that involve human activity. The global supply chain can be considered such a system. However, it has neither been systematically examined from this perspective.
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Content ArticleHuman-centered design is about understanding human needs and how design can respond to these needs. With its systemic humane approach and creativity, human-centered design can play an essential role in dealing with today’s care challenges. Design’ refers to both the process of designing and the outcome of that process, which includes physical products, services, procedures, strategies and policies. In this Melles et al., address the three key characteristics of human-centered design, focusing on its implementation in health care: (1) developing an understanding of people and their needs; (2) engaging stakeholders from early on and throughout the design process; (3) adopting a systems approach by systematically addressing interactions between the micro-, meso- and macro-levels of sociotechnical care systems, and the transition from individual interests to collective interests.
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Content ArticleDespite the application of a huge range of human factors (HF) principles in a growing range of care contexts, there is much more that could be done to realise this expertise for patient benefit, staff well-being and organisational performance. Healthcare has struggled to embrace system safety approaches, misapplied or misinterpreted others, and has stuck to a range of outdated and potentially counter-productive myths even has safety science has developed. One consequence of these persistent misunderstandings is that few opportunities exist in clinical settings for qualified HF professionals. Instead, HF has been applied by clinicians and others, to highly variable degrees—sometimes great success, but frequently in limited and sometimes counter-productive ways. Meanwhile, HF professionals have struggled to make a meaningful impact on frontline care and have had little career structure or support. However, in the last few years, embedded clinical HF practitioners have begun to have considerable success that are now being supported and amplified by professional networks. The recent COVID-19 experiences confirm this. Closer collaboration between healthcare and HF professionals will result in significant and ultimately beneficial changes to both professions and clinical care.
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Content ArticleA large proportion of the patient injuries or deaths attributable to medical device misuse can be eliminated and/or mitigated by adopting an effective human factors and ergonomics (HFE) approach. The implementation of a usability engineering process is now mandatory for medical devices manufacturers seeking to obtain the European Union’s CE Mark. In this article, Pelayo, Marcilly and Bellandi describe the European Union’s HFE regulation and highlight the challenges faced by (i) manufacturers implementing this regulation and (ii) regulatory bodies charged with assessing the compliance of usability files. In Europe, 95% of MD manufacturers are small- and medium-sized enterprises; compliance with the CE Mark regulations is a real challenge to their competitiveness. Levels of knowledge about HFE vary greatly from one regulatory organisation to another, which can sometimes lead to very different expectations. The authors also present the specific use-related risk management approach required by the HFE regulation. Lastly, they focus on the limitations of the HFE regulation for MDs and on future HFE challenges in further reducing and/or eliminating MD use errors. The main challenge is the need to go beyond technology design and the premarket assessment and to look at the postproduction stage; the coupling between an MD and a sociotechnical system can lead to consequences that were not predicted during the design process. This implies the need to consider the emerging properties of technologies in use by involving all the stakeholders.
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Content Article
Ergonomics to support the COVID-19 response
Patient Safety Learning posted an article in Process improvement
Without embedded experience within healthcare organisations the application, evidence and business case for human factors in NHS decision-making will not be developed. The concerns about availability of ventilators offered the first opportunity to support the NHS. A rapid response project was initiated to support the design, development, usability testing and operation of new ventilators. This article from the Chartered Institute of Ergonomics & Human Factors looks at their response to the rapidly manufactured ventilators and their five-step approach response that was used to influence both strategy and practice to address concerns about changing safety standards and the detailed design procedure with ventilator manufacturers. It also discusses organisational learning and achieving sustainable change and the next steps in patient safety. -
Content ArticleIt has been estimated that, on average, a serious mistake in medication administration occurs once in every 133 anaesthetic medications. Anaesthetic medications often have a narrow therapeutic window, raising the potential for adverse outcomes including harmful physiological disturbances, awareness, anaphylaxis and even death. Marshall and Chrimes in this editorial examine the causes of the medication‐handling problem and discuss solutions that address the human factors considerations.
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Content ArticleA conversation with John Wilkes (AstraZeneca), Clifford Berry (Takeda), Amy D. Wilson, Ph.D. (Biogen), and Jim Morris (NSF Health Sciences). This article is the second part of a two-part roundtable Q&A on the topic of human performance in pharmaceutical operations. Part 1 evaluated the underpinnings of human performance and provided advice to those individuals managing rapid production scale-up to support COVID-19 production demand. Here in Part 2, human performance in the context of investigation and CAPA programmes is considered.
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Content ArticleA conversation with John Wilkes (AstraZeneca), Clifford Berry (Takeda), Amy D. Wilson, Ph.D. (Biogen), and Jim Morris (NSF Health Sciences). This article is the first part of a two-part roundtable Q&A focused on human performance in pharmaceutical operations. Part 1 discusses key drivers for human performance improvement, compares lean manufacturing and human performance programmes, and provides perspectives on human performance in the context of the rapid scale-up and production of COVID-19 therapeutics and vaccines. Part 2 reviews human performance in the context of company investigation and CAPA programmes.
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Content Article
Vaccination centres: minimising the risks to vulnerable people
Patient Safety Learning posted an article in Blogs
Jane Carthey, Human Factors and Patient Safety Specialist, shares her reflections on COVID-19 vaccination centres and the risk they may present for covid transmission. -
Content ArticleA report from MedStar Health National Center for Human Factors in Healthcare on the work and research they do in human factors.
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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.
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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.
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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.
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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 ArticleA short article from NHS Education for Scotland about Significant event analysis (SEA). Enhanced SEA is a well-established safety improvement tool in general practice. However, there is good evidence to suggest that many SEAs are poorly conducted by practice teams, leading to missed opportunities to make health care safer.
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Content ArticleThreat and Error Management (TEM) is an overarching safety concept regarding aviation operations and human performance. TEM is not a revolutionary concept, but one that has evolved gradually, as a consequence of the constant drive to improve the margins of safety in aviation operations through the practical integration of Human Factors knowledge. TEM was developed as a product of collective aviation industry experience. Such experience fostered the recognition that past studies and, most importantly, operational consideration of human performance in aviation had largely overlooked the most important factor influencing human performance in dynamic work environments: the interaction between people and the operational context (i.e., organisational, regulatory and environmental factors) within which people discharged their operational duties. This article gives the background to TEM, components of the TEM Framework, related articles and further reading.
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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.
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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.
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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
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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.
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Content ArticleArterial lines are routinely fitted for severely ill patients in critical care and are flushed with a solution to maintain patency, and ensure that blood does not clot in the line. Saline is recommended as the flush solution for arterial lines. There are several examples of glucose solutions being inadvertently and incorrectly used to flush arterial lines. This has lead to inaccuracies in blood glucose measurements, which resulted in unnecessary administration of insulin and subsequent cases of hypoglycaemia, some of which have been fatal.
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Content ArticleIn 2008, the UK National Patient Safety Agency (NPSA) made recommendations for safe arterial line management. Following a patient safety incident in their intensive care unit (ICU), Leslie et al. surveyed current practice in arterial line management and determined whether these recommendations had been adopted. They contacted all 241 adult ICUs in the UK; 228 (94.6%) completed the survey. Some NPSA recommendations have been widely implemented – use of sodium chloride 0.9% as flush fluid, two‐person checking of fluids before use – and their practice was consistent. Others have been incompletely implemented and many areas of practice (prescription of fluids, two‐person checking at shift changes, use of opaque pressure bags, arterial sampling technique) were highly variable. More importantly, the use of the wrong fluid as an arterial flush was reported by 30% of respondents for ICU practice, and a further 30% for practice elsewhere in the hospital. This survey provides evidence of continuing risk to patients.
