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Showing results for tags 'Human factors'.
Found 549 results
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Content ArticleEach quarter, the Patient Safety Movement Foundation hosts a free webinar to address a central patient safety topic. This virtual workshop session on the importance of human factors and systems safety focuses on re-designing work as opposed to re-designing the human who does the work. Incorporating a human factors and systems safety approach allows for the development and integration of knowledge, skills and attitudes that facilitate successful performance at the front lines of care. Healthcare leaders will learn how to apply human factors and systems safety concepts to understand true hazards in their organizations while fostering a culture of safety.
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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 ArticleBC PSLS met with Wrae Hill, Human Factors and System Safety, Interior Health (IH), to discuss medication error traps. They use the example of an anaesthetist who, during an emergency C-section, under time constraint, gave their patient the drug cisatracurium instead of succinylcholine. Both medications are used for muscle relaxation and paralysis, however cisatracurium has a much longer duration of action. Cisatracurium was available in the Labour and Delivery Suite, but the vial cap of cisatracurium had previously been blue, yet today it was red. This ‘medication error trap’ – a recurrent situation that predictably snares a large number of different people – resulted in the patient having to be ventilated for longer than anticipated.
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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 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 ArticleThis chapter from Patient Safety and Quality: An Evidence-Based Handbook for Nurses describes a framework for understanding how human factors affect patient safety. It illustrates how different cumulative factors result in errors and suggests that nurses have a unique role to play in identifying problems and their causes. The authors highlight staff mindfulness as a tool to transform healthcare organisations into 'highly reliable organisations'.
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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.
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Content ArticlePatient safety is often compromised by confusion over the graphic information on drugs packaging. Injectable medicines are particularly susceptible to medical error. This study gives design guidance to make such packs safer.
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Content ArticleModels and methods of work system design need to be developed and implemented to advance research in and design for patient safety. In this paper, Carayon et al. describe how the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, which provides a framework for understanding the structures, processes and outcomes in health care and their relationships, can be used toward these ends. An application of the SEIPS model in one particular care setting (outpatient surgery) is presented and other practical and research applications of the model are described.
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Content ArticleOver the last 20 years, the Royal College of Art has been a fierce proponent of the role of design to improve and save lives, leading the debate on the efficacy of design thinking when applied to real societal needs. Nowhere is this better exemplified than by its impact on healthcare and patient safety. With increasing pressure on the national healthcare system, public services and provisions have to meet ever more stringent financial, resource and efficiency objectives. The Royal College of Art has demonstrated how systems-led thinking and a design approach to understanding the user’s needs can effectively reduce infection and medical error, and improve treatment spaces and patient communication.
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WHO: Guidance for after action review (1 April 2019)
Patient Safety Learning posted an article in WHO
The WHO guidance for after action review (AAR) presents the methodology for planning and implementing a successful AAR to review actions taken in response to public health event, but also as a routine management tool for continuous learning and improvements. Four formats of AARs are described including the debrief, working group, key informant interview and mixed method AARs, and the accompanying toolkits containing materials to support the designing, preparing, conducting, and following up on each AAR format. Whilst the AAR methodology described in this document can be used for any response, a specific guidance to conduct an AAR following the response to emergencies that were not caused by biological hazards such as natural disasters is also provided to help the health sector to review its specific contribution to the multisectoral response and coordination. -
Content Article‘In Safe Hands’ is an interactive guide produced by Health Education England (HEE) who is responsible for delivering education and training that supports safer clinical practice across the NHS. This guide has been produced in response to the recommendations made in the 2016 report ‘Improving Safety Through Education & Training’.
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Content ArticleIn this blog, Steven Shorrock reflects on why are we so resistant to change.
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Content ArticleHealthcare practitioners, patient safety leaders, educators and researchers increasingly recognise the value of human factors/ergonomics and make use of the discipline's person-centred models of sociotechnical systems. This paper from Holden et al. first reviews one of the most widely used healthcare human factors systems models, the Systems Engineering Initiative for Patient Safety (SEIPS) model, and then introduces an extended model, ‘SEIPS 2.0’. SEIPS 2.0 incorporates three novel concepts into the original model: configuration, engagement and adaptation. The concept of configuration highlights the dynamic, hierarchical and interactive properties of sociotechnical systems, making it possible to depict how health-related performance is shaped at ‘a moment in time’. Engagement conveys that various individuals and teams can perform health-related activities separately and collaboratively. Engaged individuals often include patients, family caregivers and other non-professionals. Adaptation is introduced as a feedback mechanism that explains how dynamic systems evolve in planned and unplanned ways. Key implications and future directions for human factors research in healthcare are discussed.
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An encounter with an error trap by Steve Highley (6 August 2015)
Sam posted an article in Error traps
Steve Highley looks at responding positively to error using a personal experience involving his car and highlights how to find and deal with error traps. -
Content ArticleIn these presentation slides, Paul Gantt and Ron Gantt, Safety Compliance Management, discuss human error and its effect on occupational safety. They identify the role of error traps in human error, how an organisation can identify and eliminate error traps to prevent incidents and they review case studies involving human error.
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The human error trap (7 June 2017)
Patient Safety Learning posted an article in Error traps
Phillip Ragain, director of training and human performance at The RAD Group, explains why it wrong to focus on human error when an incidence occurs. A majority of incident investigations correctly identify employees who made mistakes or deviated from policies and procedures, but this distracts from other causal factors and preclude better corrective actions. In his blog, Philip discusses how leaders can avoid the human error trap. -
Content ArticleThis blog discusses how competition can help drive improvement up to a point, but after which it may perpetuate unnecessary harm. It gives examples of where competition can become unhealthy. A more constructive approach requires collaboration focusing on patients to ensure they receive the best possible care.
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Content ArticleThis blog from the PatientSafe Network discusses cognitive dissonance. Cognitive dissonance — the pain of accepting ego-dystonic facts — mitigates against an open, rational aggressive cycle of process improvement. Unfortunately the hierarchical structures in healthcare mean we are likely to suffer from this. Those further up, best positioned to bring about positive change, are the most likely to suffer cognitive dissonance.
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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 ArticleDr Maryanne Mariyaselvam, doctoral researcher in patient safety at Cambridge University, and Dr Peter Young, consultant in anaesthetisa and critical care at Queen Elizabeth NHS Trust, King’s Lynn, on how human factors thinking and design enabled two new patient safety innovations.
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Content ArticleAlthough many initiatives have been implemented and great strides have been achieved in improving patient safety and reducing preventable medical errors, progress towards achieving "zero" avoidable harm continues to be slow. This video presentation will address common medical errors, their recognition, potential for harm and the psychological and financial costs. The concepts of human factors, system design and the high reliability organisation will be reviewed. New approaches in reducing harm and restoring trust will be described along with the opportunity for physician leadership.
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Content ArticleTo find out how checklists and monitoring work in actual practice, Benjamin and Dismukes observed line operations during 60 flights conducted by three air carriers from two countries. They used a structured technique to observe and record checklist and monitoring performance, and situational factors that might affect performance. Because an important function of checklists and monitoring is to catch, or “trap,” operational errors, they also recorded deviations in aircraft control, navigation, communication and planning. When a deviation was observed, they tracked whether crewmembers identified and corrected it, and whether there were any consequences that might affect the outcome of the flight. They found that checklists and monitoring are not as effective as generally assumed.
