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Content ArticleOn Monday 10 July 2023 the Centre for Perioperative Care (CPOC) and Patient Safety Learning jointly hosted a webinar on the new National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). This article contains links to video recordings of this webinar.
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Content Article
It has become fashionable to purge the term ‘error’ from the safety narrative. Instead, we would rather talk about the ‘stuff that goes right’. Unfortunately, this view overlooks the fact that we depend on errors to get things right in the first place. We need to distinguish between an error as an outcome and error as feedback, writes Norman MacLeod in this blog for the hub.- Posted
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Event
Error and systems-based solutions to patient safety
Sam posted an event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-based-solutions-patient-safety-masterclass or email frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org -
Event
Systems approach to patient safety including Human Factors
Sam posted an event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-approach-patient-safety-masterclass or email frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. -
Content ArticlePoorly designed electronic health records (EHRs) are common, and research shows poor design consequences include clinician burnout, diagnostic error, and even patient harm. One of the major difficulties of EHR design is the visual display of information, which aims to present information in an easily digestible form for the user. High-risk industries like aviation, automotive, and nuclear have guidelines for visual displays based on human factors principles for optimised design. In this study, Pruitt et al. reviewed the visual display guidelines from three high-risk industries—automotive, aviation, nuclear—for their applicability to EHR design and safety.
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Content ArticleAll Systems Ergo, invites Human Factors specialists from around the world to share their experience of incorporating Human Factors into their field of work and the impact it has had to support patient outcomes and improve care within healthcare. Hosted by Fran Ives, Chartered Human Factors Specialist, the bi-weekly podcast discusses a number of key human factors topics including transportation, patient safety and product design, as well as personal stories of industry professionals’ inspiring career journeys.
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Content ArticleIn this blog, Clare Crowley and Nick Woodier, National Investigators at the Healthcare Safety Investigation Branch (HSIB) look at the simple but often overlooked measures that NHS staff and organisations can take to improve the design and display of information in the workplace. They refer to a recent HSIB investigation that highlighted how the choice of information to display, and the visibility and accuracy of that information, can influence how NHS staff access and use it.
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Our heavily curated Instagram society has become very intolerant of error. In an era where everything we present is airbrushed, tweaked, filtered and polished before being released into the wild, we labour under the misapprehension that the real world is similar. We are sadly mistaken. The real world is messy, imperfect and error-prone. In this blog, Niall Downey talks about his book, Oops! Why Things Go Wrong, which explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, how it is sometimes actually quite efficient from a physiological standpoint and, most importantly, what we can do about it. -
Content ArticleStructured into four major sections this white paper, from the Chartered Institute of Ergonomics & Human Factors, helps you learn background information and context for the role of people in barrier systems. It sets out concerns about the way human and organisational factors are currently treated in some approaches to barrier management and in Bowtie Analysis in particular.
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"I am thirty miles south of London’s Gatwick Airport, the world’s busiest single-runway airport, when one of the seven Flight Control computers in my Airbus A320 aircraft fails . . . ’ So begins this pioneering book by Niall Downey – a cardio-thoracic surgeon who retrained to become a commercial airline pilot – where he uses his expertise in medicine and aviation to explore the critical issue of managing human error. With further examples from business, politics, sport, technology, education and other fields, Downey makes a powerful case that by following some clear guidelines any organisation can greatly reduce the incidence and impact of making serious mistakes. While acknowledging that in our fast-paced world getting things wrong is impossible to avoid completely, Downey offers a strategy based on current best practice that can make a massive difference. He concludes with an aviation-style Safety Management System that can be hugely helpful in preventing avoidable catastrophes from occurring. -
Content Article
Adverse incidents arising from suboptimal healthcare are a major cause of worldwide morbidity and mortality. Arriving at an understanding of the conditions under which adverse incidents occur has the potential to improve the safety of healthcare provision. Staff working in the NHS have been contributing their experiences via a narrative data capture platform – SenseMaker – to help gain contextual insights on a wide range of topics under exploration by the NHS Horizons team. This blog by Rosanna Hunt (Senior Associate, NHS Horizons) in collaboration with Lizzy MacNamara (Junior Research Consultant, The Cynefin Co.) and Taj Nathan (Consultant Forensic Psychiatrist, Cheshire & the Wirral Partnership Foundation Trust) describes how the SenseMaker® platform could be used to extract staff experiences on the topic of patient safety incidents both reported and unreported by staff, and the facilitated conversations that would be needed to transform the data into actionable insights and commitment to change. -
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 ArticleThis paper from Roberts et al. examines the application of the Surgical Safety Checklist (SSC) within NHS hospital operating theatres England. The aim of the study, through a combination of open-ended questions, was to solicit specific information including views and opinions from operating theatre experts to establish from how the World Health Organisations (WHO) SSC is being applied, and therefore and why intraoperative ‘Never Events’ continue to occur more than a decade after the SSC was introduced. Participants were from the seven regions identified by NHS England. The intention of this paper is not to establish definitively whether the quantitatively identified themes; including a lack of training and engagement with human factors explains the increased presence of intraoperative ‘Never Events’. However, these themes, when subjected to methodological triangulation with the current literature, do appear consistent, and therefore provide an exploratory approach to inform research intended to improve safety in the operating theatre by informing policy and its application to safe practice ultimately towards quality improvements.
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Content Articlehe NHS needs every one of its 1.4 million staff, but nobody is perfect every day of their career. Human factors have a huge impact on staff and patients. After witnessing poor behaviour in the workplace, co-workers are less effective and patients have worse outcomes. An unpleasant working culture also reduces camaraderie in teams and can lead to resignations. This is a vicious cycle of overwork and burnout that the NHS can’t afford. We need to nurture our workforce. In this BMJ opinion article, Scarlett McNally suggests focusing on three areas: expecting a minimum standard of behaviour at all times rather than perfectionism; identifying when intense focus is needed; and building effective teams. The minimum standard should be an expectation of “respect” at all times.
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Content ArticleMedication error may occur for a variety of reasons. One of the most common sources of medication error is related to look-alike and sound-alike (LASA) drugs as well as the often-similar appearances of the vials. LASA medications are typically thought of as medications that are similar in physical appearance related to packaging as well as medications whose names are similar in spelling or in the phonetic pronunciation. Tricia A. Meyer looks at cases of LASA drugs and prevention techniques. She concludes that healthcare professionals, safety groups, and professional organisations should continue to work with manufacturers, regulators, and naming entities to explore opportunities to minimise the LASA risks for drugs that are either new to the market or in the pre-marketing stage. Further information on the hub Take a look at our Error traps gallery on the hub
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Content Article
Complexity resources (NHS England)
Patient-Safety-Learning posted an article in NHS England
NHS England has collated this set of resources about understanding complexity. Understanding complexity video by NHS Horizons Understanding and Working with Complexity blog by Andrew Singfield Spread and Complexity in the NHS blog by Diane Ketley Looking at Spread – Three Helpful Lenses blog by Diane Ketley Spreading and scaling up innovation and improvement paper by Trisha Greenhalgh Changing how we think about healthcare improvement paper and audio recording by Jeremy Braithwaite ‘Adaptive Spaces’ for an emerging future blog by Q community What is Adaptive space? A Brief Introduction video by Gareth Evans Adaptive Space in Action video by Matthew Mezey Adaptive space – Overview of the work of Mary Uhl-Bien video by Diane Ketley How ‘Adaptive Spaces’ enable innovation in healthcare and beyond webinar with Mary Uhl-Bien How to master the art of creating ‘Adaptive Spaces webinar with Mary Uhl-Bien Mary Uhl-Bien in Conversation: COVID-19, complexity leadership and spread of innovation video recording with Mary Uhl-Bien Adaptive spaces, networks…. and a challenge called spread blog by Diane Ketley Complexity leadership theory: Shifting from Human Capital to Social Capital paper by M Arena and Mary Uhl-Bien How to Catalyse Innovation in Your Organisation paper by M Arena et al Navigate Complexity: Three Habits of Mind blog by Sonja Blignaut Three habits of mind video by Jennifer Garvey Berger and Keith Johnston Cynefin framework introduction video and book chapter by Jennifer Garvey Berger and D Snowden Stacey framework blog and video recording by R Stacey -
EventThis one day masterclass will focus on improving Patient Safety through enhancing psychological safety and safety culture. We will look at effective ways to encourage health professionals to routinely embed high-quality clinical evidence into their everyday work. We will explore the characteristics of relatively successful behaviour change interventions. Key learning objectives: Psychological safety. Safety culture. Behaviour. Human Factors. How to improve safety reporting. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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Content ArticleECRI is an independent non-profit that produces an annual list of Top 10 Patient Safety Concerns, and its list for 2023 includes a new emphasis on system safety. In this interview for the Betsy Lehman Center, two leaders at ECRI talk about the list and the current state of patient safety. Shannon Davila, ECRI’s Director of Total Systems Safety and Marcus Schabacker, President and CEO, discuss the need to address gaps in performance with a "total systems approach," the ongoing issue of health inequity and the patient safety risks associated with recent changes in state laws and guidance around obstetrics and maternity.
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Content Article
In this blog, hub topic lead Julie Storr talks about her new book Infection prevention and control: A social science perspective, which explores new perspectives on and approaches to infection prevention and control (IPC). The book examines how people and their behaviour affect IPC, and how they are in turn affected by IPC measures. Julie highlights the importance of compassion in IPC policy and implementation and outlines the unintended negative consequences that IPC measures can have. Among other contributors, Patient Safety Learning's Chief Executive Helen Hughes has written a chapter for the book highlighting the need for patient safety to be treated as a core purpose of health and social care.- Posted
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Content ArticleWhen people don't feel their actions will make a difference because of the vast scale of a problem, they are less likely to act, and this has implications for attempts to improve patient safety and reduce avoidable harm. In this article, Brian Resnick, science and health editor at Vox, interviews psychologist Paul Slovic, who has been researching human responses to risk and compassion since the 1970s. They discuss the psychological impact of large numbers of people on our ability and willingness to respond compassionately and to act on that compassion. They look at Slovic's research into the concepts of psychic numbing and the prominence effect, focusing on the global refugee crisis and why individuals and governments fail to act in the face of immense suffering.
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Content ArticleDoes your manufacturing facility experience an undesirable frequency of costly product losses? Are recurring operational issues impacting productivity and morale? Do people believe the causes of these production issues are ‘human error’? Do Quality Differently will show you: How to take a systems-based risk management approach to create more operational success. Practical examples to guide improvement in your operations. Ways to apply comprehensive approaches that reveal and address the combination of factors that influence performance outcomes.
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Content Article
The term 'Gemba Walk' is derived from the Japanese word 'Gemba' or 'Gembutsu' which means 'the real place', so it can be literally defined as the act of seeing where the actual work happens. A safety Gemba Walk, or Gemba safety walk, is a safety walk integrated with the Gemba method, emphasising the continuous improvement of safety by watching the actions required to complete daily tasks and determine ways to make work safer. While a typical site safety walk through aims to maintain compliance with safety standards, a safety Gemba Walk focuses on looking for opportunities to continuously improve workplace safety. This article describes the Gemba Walk method and includes information on: What is a Safety Gemba Walk? What is a Virtual Gemba Walk? Why are Gemba Walks important? Benefits How to do a Gemba Walk Process How often should you do a Gemba Walk? Effective ways to do a Gemba Walk Examples -
Content ArticleEnsuring organisations learn from patient safety incidents is a key aim for healthcare organisations. The role that human factors and systems thinking can have to enable organisations learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems. Investigation of incidents has previously been rooted in reductionist methodologies, for example, seeking to find the ‘root cause’ to individual incidents. While healthcare has embraced, in some contexts, the option for system-based methodologies—for example, SEIPS and Accimaps—these methodologies and frameworks still operate from a single incident perspective. It has long been acknowledged that healthcare organisations should focus on near misses and low harms with the same emphasis as incidents resulting in high harm. However, logistically, investigating all incidents in the same way is difficult.
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Content ArticleOn paper, a GP’s working schedule can look quite inviting: consulting for three and a half hours in the morning, with a coffee break in the middle, then a gap for lunch and home visits before a similar length afternoon surgery. However, this is rarely the reality for NHS GPs. In this BMJ opinion piece, GP Helen Salisbury talks about what working life is really like for GPs and highlights the mismatch between their scheduled hours and tasks and the reality, which often involves them doing much more. She highlights how the unrealistic demands GPs face have been exacerbated by a movement of work from secondary to primary care, and argues that this is contributing to the workforce crisis that general practice faces.
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Content Article
NHS Patient Safety Syllabus v. 2.1 (June 2022)
Patient Safety Learning posted an article in Training & education
The Academy of Medical Royal Colleges and the University of Warwick have developed this NHS Patient Safety syllabus to complement it as the basis for education and training for staff throughout the NHS.
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