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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.
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Content ArticleThe COVID-19 pandemic has had one of the biggest effects on work-as-done in healthcare in living memory. So what might we learn about work from the perspectives of frontline workers? Steven Shorrock asked a variety of practitioners to give a short answer – whatever came to mind. The themes that emerge centre around people, their activities, their contexts, and their tools. Many insights concerned the varieties of human work, goal conflicts, design, training, communication, teamwork, social capital, leadership, organisational hierarchy, problem solving and innovation, and – generally – change. Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives.
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Content Article
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. Dan talks to us about how his experiences as a paediatrician and military doctor have influenced his view of patient safety. He also describes the increasing complexity in healthcare systems and highlights the need for the Government to commit policy and resources to building and sustaining the NHS workforce. -
Content ArticleThe NHS Patient Safety Incident Response Framework (PSIRF) promotes a range of system-based approaches for learning from patient safety incidents. These national tools and guides have been developed to incorporate the well-established SEIPS framework (Systems Engineering Initiative for Patient Safety) to help support organisations implementing PSIRF.
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Content ArticleIn this article, Professor Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), outlines an NES research project which aimed to critically review the safety-related content, language and assumptions of a small but diverse range of health and care safety learning reports, policies, databases and curricula.
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Content ArticleAn examination of how humans interact with their environments and each other led this team to question one of its long-standing medication safety practices and change how they work.
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Content Article
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 ArticleLoughborough University offers online accredited Healthcare Human Factors short courses to support the NHS Patient Safety Strategy and guide the learner into a new way of thinking about safety in healthcare. The professional Learning Pathway provides a complete programme for the Human Factors (Ergonomics) content in the Patient Safety Syllabus that you need to develop your knowledge and skills as a Safety Specialist, integrating both patient safety and staff wellbeing. By completing the pathway through to Level 3, you can achieve a professional qualification as a Human Factors Technical Specialist (TechCIEHF); or alternatively, you can use the individual online learning modules for CPD.
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Content ArticleIn July 2019, NHS England and NHS Improvement launched the NHS National Patient Safety Strategy. A key element of this is the development and implementation of a patient safety syllabus, which was created by Academy of Medical Royal Colleges (AoMRC) based on a proactive approach to the prevention of harm. UCLPartners is working in partnership with the Chartered Institute for Ergonomics and Human Factors’ (CIEHF) Lantern Group to support Trusts across London to assess their readiness to implement the syllabus through the development of an organisational self-assessment tool. This work has been commissioned by Health Education England (HEE). The organisational self-assessment tool has been developed alongside a Facilitator’s Guide.
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Content Article
Loughborough University and the Chartered Institute of Ergonomics & Human Factors have been working on a Human Factors Healthcare Learning Pathway since the launch of the CIEHF White Paper in 2018 and it’s finally arrived. The Learning Pathway is aligned to the National Patient Safety Syllabus and focusses on Human Factors. Human Factors is a broad, scientific, evidence-based discipline that can help people solve a wide range of problems that they face in what they do, every day. In understanding, for example, why patients struggle to use personal medical devices, the application of Human Factors in the design, implementation and evaluation of the devices or in the equipment we use, and the way people work, individually and together, will lead to more resilient, more productive, more connected and more sustainable systems and ways of working (see HEE and CIEHF report 'Human Factors and Healthcare'). Professor Sue Hignett, one of the developers of the course, explains more. -
Content ArticleHealth Education England, Loughborough University and a range of partners have developed the new Human Factors Healthcare Learning Pathway in response to the NHS Patient Safety Syllabus 2021. It is the first ever system-wide Patient Safety Syllabus and is available as e-learning short courses that can be completed as a Learning Pathway (Levels 1-3) or individually. Fully accredited by the Chartered Institute of Ergonomics and Human Factors (CIEHF) and the CPD Certification Service, the Pathway offers a complete programme for health and social care staff to: develop competence and capability in Human Factors (Ergonomics) focus their knowledge on patient safety and staff wellbeing. Level 1 is available for free on the NHS Education for Scotland TURAS system and Health Education England's e-Learning for Healthcare platform Selected Level 2 modules are available to book on the Loughborough University Healthcare Learning Pathway webpage
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Content ArticlePatient safety continues to be a significant issue in healthcare and a focus of both quality improvement and academic research. The NHS published its first Patient Safety Strategy in July 2019. As part of this, it was agreed that the first NHS-wide Patient Safety Syllabus would support a transformation in patient safety education and training in the NHS. The Patient Safety Strategy includes ambitions to develop training in the fundamentals of patient safety that would be relevant to all NHS staff, clinical and non-clinical, as well as more detailed training and education that could be incorporated into clinical and non-clinical undergraduate and postgraduate healthcare education and continuing professional development. T The syllabus is designed for all NHS staff and is structured to provide both a technical understanding of safety in complex systems and a suite of tools and approaches that will: Build safety for patients. Reduce the risks created by systems and practices. Develop a genuine culture of patient safety. The patient safety syllabus comprises five sequential domains of safety and forms the basis of the detailed curriculum guidance designed for specific levels of the NHS.
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Content ArticleHealth Education England (HEE) has published the first NHS-wide Patient Safety Syllabus which applies to all NHS employees and will result in all NHS employees receiving enhanced patient safety training. Written by the Academy of Medical Royal Colleges and commissioned by HEE the new National Patient Safety Syllabus outlines a new approach to patient safety emphasising a proactive approach to identifying risks to safe care while also including systems thinking and human factors. Level one and two learning materials will be available on the E Learning for Health platform for staff to access and complete from August and September 2021.
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Content Article
Patient Safety Syllabus training
Mark Hughes posted an article in Specialist patient safety training
The National patient safety syllabus outlines a new approach to patient safety, emphasising a proactive approach to identifying risks to safe care while also including systems thinking and human factors and applies to all NHS employees. This page provides access to learning materials (via the E-Learning for Health platform) for staff relating to Level one – Essentials for patient safety and Level two – Access to practice of the training associated with this. -
Content ArticleThis guidance from the Chartered Institute of Ergonomics and Human Factors (CIEHF) outlines how human factors as a discipline can help address issues relating to equality, diversity, and inclusion (EDI). It looks at situations that cause EDI issues, including: confusing user interface language and terminology. ill-fitting personal protective equipment (PPE). biases in equipment design. It also examines the role of human factors in overcoming these issues, by: adopting a systems approach. using a participatory design process. applying specific HF methods to enhance EDI delivery.
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Content ArticleIn this webinar, Jane O'Hara, Professor of Healthcare Quality and Safety at the University of Leeds, outlines how understanding of the role of patients and families in supporting patient safety has developed over the past few years. She highlights the work of the Yorkshire Quality and Safety Research Group (YQSR) and looks at research demonstrating the role patients and families can play in improving the safety of healthcare systems.
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Content ArticleThis report describes an adverse incident at Queen's Medical Centre in Nottingham in 2001, when a male patient being treated for leukaemia died after being mistakenly given the chemotherapy drug Vincristine intrathecally (into the spine). Vincristine should be administered intravenously, and accidental intrathecal administration of Vincristine is almost always fatal.
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Content ArticleMersey Care NHS Foundation Trust is committed to delivering perfect care but this depends on the development of a just and learning culture.
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Content ArticleThis guidance aims to support the safe roll-out of COVID-19 vaccination programmes. Vaccination programmes include a number of work systems, such as manufacturing, filling and packaging for distribution, testing and approval, cold chain delivery, booking systems for vaccination appointments, local administration of the vaccine, and patient follow-up. The challenges and requirements for operating such complex programmes at speed may vary both within a country as well as between countries, but the guidelines offer 10 principles to support systems thinking for vaccination programmes that apply across settings. These human factors and ergonomic principles relate to the identification and description of work systems (Identify), the improvement of work systems and processes (Improve), and the continuous learning from experience to achieve sustainable change (Adapt).
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Community PostTwo vaccines for COVID-19 have now been approved. Health organisations are doing their upmost to workout how best to store and administer the vaccines safely and avoiding errors. The Chartered Institute of Ergonomics and Human Factors (CIEHF) are preparing strategic guidance for health authorities and operational guidance for people setting up vaccine programmes applicable internationally. In a recent LinkedIn post, Chief Executive Noorzaman Rashid asks: "What are the Human Factors and Ergonomic issues that should be considered?" And asks you to share your ideas: https://www.linkedin.com/posts/noorzamanrashid_the-economist-on-twitter-activity-6750290388721926144-h8XV/ #ciehf #covid #patientsafety
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