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Showing results for tags 'Human factors'.
Found 549 results
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Content Article
Rethinking healthcare as a safety-critical industry
Patient Safety Learning posted an article in Barriers
The discipline of ergonomics, or human factors engineering, has made substantial contributions to both the development of a science of safety, and to the improvement of safety in a wide variety of hazardous industries, including nuclear power, aviation, shipping, energy extraction and refining, military operations, and finance. It is notable that healthcare, which in most advanced societies is a substantial sector of the economy and has been associated with large volumes of potentially preventable morbidity and mortality, has not up to now been viewed as a safety critical industry. This paper from Robert L Wears proposes that improving safety performance in healthcare must involve a re-envisioning of healthcare itself as a safety-critical industry, but one with considerable differences from most engineered safety-critical systems. This has implications both for healthcare, and for conceptions of safety-critical industries. -
Content Article
Breaks from operational duty are an important factor in the management of fatigue. But as highly committed and professional operational staff often perform several secondary tasks and activities—inside or outside the ops room—breaks can become a victim. This blog by Chartered Ergonomist and Human Factors Specialist Stephen Shorrock offers some general guidelines about what kinds of tasks add to stress and fatigue and should be avoided during rest breaks. He places break activities into three categories which place different demands on the individual: red, amber and green activities. He also highlights that when it comes to breaks from operational duty, changes in activity are the key to reducing fatigue-related risks. -
Content Article
What is a Gemba Walk? (SSDSI)
Patient-Safety-Learning posted an article in Improving systems of care
This blog describes the Gemba Walk technique, a popular LEAN management method. During a Gemba Walk, leaders gain valuable insight into the flow of value within the organisation by visiting the workplace and interacting with employees. Leaders also learn new ways to support their employees. The approach encourages collaboration between employees and the leaders. The article covers: What is a Gemba Walk? Three important components of the Gemba Walk Gemba Walk planning, execution and follow-up Get the team ready Develop a plan Follow the Value Stream Never lose sight that the process as a problem (not the people) Keep a record of your observations Ask questions Do not suggest changes during the walk Participate in teams Who should go on a Gemba Walk? Follow up with employees Return to the Gemba An example Gemba Walk Checklist -
Content ArticleThis blog by Operations Insider looks at the Gemba Walk approach to problem solving in systems. Gemba Walks involve looking at problems where they occur and discussing them on site, in the real world. The blog includes a series of questions to consider when using the Gemba Walk approach,
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Content ArticleTo overcome the problem of development teams losing sight of the detail of processes they are trying to improve, Toyota developed what they call a 'Gemba Walk'. The translation of the term from the root Japanese word is 'the real place' or 'the place where value is created'. This article describes how a Gemba Walk works, how it has been adapted for different industries and the value of engaging both leaders and employees in the process.
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Content ArticleWhether beginning a new effort or trying to keep people motivated to better prepare for future hazards, applying risk communication principles will lead to more effective results. This self-guided module introduces seven best practices, numerous techniques, and examples to help you improve your communication efforts. Please note that this training focuses on improving risk communication skills for coastal hazards planning and preparedness, however the principles can be adapted for any setting, including healthcare.
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Content ArticleMedical equipment, supplies, and devices (ESD) serve a critical function in healthcare delivery and how they function can have an impact on patient safety. ESD-related safety issues include malfunctions, physically missing ESDs, sterilisation and usability. Describing ESD-related safety issues from a human factors perspective that focuses on user interactions with ESDs can provide additional insights to address these issues. This article in the journal Patient Safety reviewed ESD patient safety event reports submitted to the Pennsylvania Patient Safety Reporting System to identify ESD-related safety issues.
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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 ArticleAdherence to best practices for sepsis management at a small community hospital was below system, state and national benchmarks and affected vital indicators, including mortality. This study carried out by Megan Kiser aimed to improve sepsis best practice compliance by implementing human factors–influenced interventions.
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Content ArticleIn this blog, interdisciplinary humanistic, systems and design practitioner Dr Stephen Shorrock explores the dangers of project leaders relying on assumptions about work-as-imagined, detached from the reality of contextualised work-as-done. He describes his experience working on a project in which he discovered that operational staff felt anxious and unprepared for the major changes to come. This was unacknowledged by management, and he ascribes their lack of awareness to a failure to physically and empathetically engage with the workers in the reality of the processes and systems management had designed. He highlights the importance of empathy and asks the question, "In your worlds, how connected are managers and other non-operational specialists with operational staff and the operational environment, where changes ultimately end up? Those who wish to support operational staff through change must take the role of pupil, or apprentice – not master."
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Content ArticleFailure to rescue is defined as mortality after complications during hospital care. Incidence ranges 10.9%–13.3% and several national reports such as National Confidential Enquiry into Patient Outcomes and Death and National Institute of Clinical Excellence CG 50 highlight failure to rescue as a significant problem for safe patient care. To avoid failure to rescue events, there must be successful escalation of care. Studies indicate that human factors such as situational awareness, team working, communication and a culture promoting safety contribute to avoidance of failure to rescue events. Understanding human factors is essential to developing work systems that mitigate barriers and facilitate prompt escalation of care. This qualitative evidence synthesis identifies and synthesise what is known about the human factors that affect escalation of care.
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Content ArticleAlarms are signals intended to capture and direct human attention to a potential issue that may require monitoring, assessment or intervention. They play a critical safety role in high-risk industries such as healthcare, which relies heavily on auditory and visual alarms. While there are some guidelines to inform alarm design and use, alarm fatigue and other alarm issues are challenges in the healthcare setting. The automotive, aviation, and nuclear industries have used the science of human factors to develop alarm design and use guidelines. This study in the journal Patient Safety aimed to assess whether these guidelines may provide insights for advancing patient safety in healthcare.
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). The new Patient Safety Strategy advises that organisations must adopt a new and broader approach to stimulate learning from patient safety incidents. This course is designed to assist healthcare professionals involved in this important work. The main purpose is to provide learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs). Traditionally, root cause analysis has been used as a blanket approach to diagnosing why patient safety have been compromised, but healthcare teams are henceforth being encouraged to adopt a wider range of methods that will both save time and facilitate enhanced learning. The focus is now on appropriate proportionality in response to incidents that occur in their organisation. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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Event
Human Factors in your work and your team
Patient Safety Learning posted an event in Community Calendar
This virtual masterclass will guide you in how to use Human Factors in your workplace. All medical and non-medical staff should attend. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. It can be used to assess 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/human-factors-workplace or email frida@hc-uk.org.uk. hub members receive a 20% discount code. Email info@pslhub.org. -
Event
Human Factors in your work and your team
Patient Safety Learning posted an event in Community Calendar
This virtual masterclass will guide you in how to use Human Factors in your workplace. All medical and non-medical staff should attend. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. It can be used to assess 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/human-factors-workplace or email frida@hc-uk.org.uk. hub members receive a 20% discount code. Email info@pslhub.org. -
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 Article
A ‘Just Culture’ aims to improve patient safety by looking at the organisational and individual factors that contribute to incidents. It encourages people to speak up about their errors and mistakes so that action can be taken to prevent those errors from being repeated. Adam Tasker and Julia Jones are graduate medical students at Warwick Medical School. They wanted to explore doctors’ perceptions of culture and identify ways to foster a Just Culture, so they conducted a qualitative research study at one of the hospitals where they were doing their medical training. We asked them about why Just Culture is important in the health and care system, and what they discovered from their research. -
Content ArticleHindsight bias (colloquially known as ‘the retrospectoscope’) is the tendency to perceive past events as more predictable than they actually were. It has been shown to play a significant role in the evaluation of an past event, and has been demonstrated in both medical and judicial settings. This study in Clinical Medicine aimed to determine whether hindsight bias impacts on retrospective case note review, through an internet survey completed by doctors of different grades. The authors found that in some cases, doctors are markedly more critical of identical healthcare when a patient dies compared to when a patient survives. Hindsight bias while reviewing care when a patient survives might prevent identification of learning arising from errors. They also suggest that hindsight bias combined with a legal duty of candour will cause families to be informed that patients died because of healthcare error when this is not a fact.
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Content ArticleThe ‘No Blame Culture’ being adopted by the NHS draws attention from individuals and towards systems in the process of understanding an error. This article in the Journal of Applied Philosophy argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. The authors argue that proponents of No Blame Culture often fail to distinguish between blaming someone and holding them responsible, They examine the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, the authors argue that a responsibility culture has significant advantages over a No Blame Culture as it can enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.
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Event
SEIPS masterclass in maternity
Patient-Safety-Learning posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply the Systems Engineering for Patient Safety (SEIPS) approach. This 2.5 hour masterclass will focus on using SEIPS in maternity. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. The course costs £50 per person. Pre and post class materials will be provided. Book a place -
Content ArticleIn this 1202 Human Factors Podcast, Rob Hutton gives us an insight into naturalistic decision making and how it takes methods out of the Lab.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) will transition into new arms-length body The Healthcare Services Safety Investigation Body (HSSIB) in October 2023. In this article, HSSIB's Chair Designate, Ted Baker, reflects on: how the Francis Inquiry was instrumental in changing the view of patient safety in the NHS. the role of HSIB over the last five years in identifying systemic causes of patient harm. what the future holds for HSSIB.
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Content ArticlePoster presentation from Dr Felicity Brokke and Ken Spearpoint at the recent GOSH Patient Safety and Human Factors Conference.
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Content ArticleThe aim of Royal Surrey's Human Factors & Team Resource Management Programme is to raise the awareness, understanding and application of the science of human factors within healthcare to improve staff and patient safety and wellbeing. Their ambition is to ensure their staff are familiar with the term 'human factors', understand what it is, how to recognise when HF dynamics affect system performance and safety, and know where to go to find out more. Take a look at their website, their programme and human factors projects.
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Content ArticleThis correspondence published in Anaesthesia reflects on the recent guidance released by the Difficult Airway Society and the Association of Anaesthetists, 'Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals'. The authors highlight that although the guidance is a positive step forward in improving system safety in anaesthesia, there is a need to include a broader range of Human Factors (HF) specialists in the development of guidelines such as these. They call for a higher level of collaboration between clinicians and HF specialists to ensure that healthcare system safety can benefit from years of HF expertise.
