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Showing results for tags 'Human factors'.
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Content ArticleMartin Bromiley is a commercial airline training Captain and founder of The Clinical Human Factors Group. This episode of the Leadership Enigma podcast is deeply personal, inspirational and thought provoking. Martin describes how he turned the loss of his wife after a surgical procedure into a mission to understand and help others embrace the need for non-technical behaviours especially during critical times. He chats about the aviation and healthcare industry in relation to themes such as deference to hierarchy, the checklist manifesto, confident humility and creating an environment where your team and organisation embrace the challenge to 'double their error rate.' Behaviours are the bedrock for living your values and creating a culture that is positive and sustainable.
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Content ArticleThis study in the International Journal for Quality in Health Care aimed to develop and test a handover performance tool (HPT) able to help clinicians to systematically assess the quality and safety of shift handovers. The study was conducted in the paediatrics, obstetrics and gynaecology wards of a UK district hospital. 30 human factor experts participated in the development phase and 62 doctors from various disciplines were asked to validate the tool. The authors found that, according to the HPT, communication determined the majority of handover quality, with teamwork and situation awareness also important factors in the overall quality rating. They found that the HPT demonstrated good validity and reliability and can be easily used by raters with different backgrounds and in several clinical settings.
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Content ArticleThis webpage provides an overview of how human factors affect outcomes in surgical emergencies. It includes: An introduction to human factors Video exploring the case of Elaine Bromiley Explanation of human error and the Swiss Cheese Model Table of factors that reduce human error 'What if?' video showing how simple changes could have resulted in a different outcome in Elaine Bromiley's case Practical tips for managing the paediatric airway in a critically ill child
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Content ArticleThe theme of this Issue of Hindsight is ‘Wellbeing’, which has an undeniable link to safe operations, though this is not often spoken about. This Issue coincides with the COVID-19 pandemic. The authors of the articles in this Issue were considering wellbeing in the context of aviation, and other industries. But the articles touch on topics that are deeply relevant to the pandemic. The spread of the virus and its effect on our everyday lives has brought the biological, psychological, social, environmental, and economic aspects of wellbeing into clear view in a way we have never seen before.
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Content ArticleThis issue of Hindsight concerns ‘the new reality’ that we are facing. It includes a wide variety of articles from frontline staff and specialists in safety, human factors, psychology, aeromedical, and human and organisational performance in aviation. There are also insights from healthcare, shipping, rail, community development and psychotherapy.
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Content ArticleThis issue of Hindsight is on the theme of digitalisation and human performance. It includes a wide variety of articles from frontline staff and specialists in technology, change, safety, human factors, and human and organisational performance in aviation. There are also insights from healthcare and pharmaceutical manufacturing. The articles reflect the possibilities for digitalisation and human performance, and the challenges for individuals, teams, organisations, regulators, industries, and societies.
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Content ArticleBlood transfusion is considered one of the safer aspects of healthcare, however potentially avoidable patient-safety incidents led to 14 deaths in the UK in 2017. Improvement initiatives often focus on staff compliance with standard operating procedures. This fails to understand adaptations made in a complex, dynamic environment, so the aim of this study from Watt et al. is to examine the extent and nature of adaptations at all stages of the vein to vein transfusion process.
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In this blog Patient Safety Learning’s Chief Executive, Helen Hughes, discusses the connection between procurement, supply chains and patient safety, ahead of an upcoming Safety for All Campaign webinar on this topic. -
Content ArticleHave you ever come across a ‘problematic solution’ that was implemented in your workplace, and wondered, “How did this come to be?” Wherever you sit in an organisation, the chances are that you have. Many problematic solutions emerge from a top-down process that Steven Shorrock in this blog will call work-as-imagined solutioneering. In this post, he outlines a typical process of 10 steps by which problematic solutions come into being. Some of the steps may be skipped, but with the same outcome: a problematic solution. At the end of the post, you will find 10 ‘solutions’ from healthcare, provided by healthcare practitioners.
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Content ArticleThroughout Jens Rasmussen’s career there has been a continued emphasis on the development of methods, techniques and tools for accident analysis and investigation. In this paper, Waterson et al. focus on the evolution and development of one specific example, namely Accimaps and their use for accident analysis.
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Pre-Hospital Care Podcast: Designing the RSI
Patient Safety Learning posted an article in Techniques
The Pre-Hospital Care Podcast is designed to have engaging and inspirational conversations with some of the World’s leading experts relating to pre-hospital care. This session interviews flight paramedic Paul Swinton, to talk about how to optimise the rapid sequence intubation (RSI) in the pre-hospital environment. It unpacks some of the nuances, challenges, and approaches that Paul has found from being both a pre-hospital practitioner and in innovating the layout and design for an RSI in creating the SCRAM bag. SCRAM™ (Structured CRitical Airway Management) is an innovative solution for enhancing the performance of emergency airway management. It involves the systemisation, standardisation, cognitive offloading, human factors and good governance are core principles to the design and philosophy of SCRAM. -
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ECRI: Top 10 Patient Safety Concerns 2022
Patient Safety Learning posted an article in International patient safety
ECRI's annual Top 10 list helps organisations identify imminent patient safety challenges. The 2022 edition features many first-time topics, and emphasis is on potential risks that could have the biggest impact on patient health across all care settings. The number one topic on this year’s list has been steadily growing throughout the COVID-19 pandemic and impacts patients and staff on all levels: staffing shortages. Prior to 2021, there was a growing shortage of both clinical and non-clinical staff, but the problem has grown exponentially. In early January 2022, it was estimated that 24% of US hospitals were critically understaffed, while 100 more facilitates anticipated facing critical staff shortages within the following week. The list includes diagnostic and vaccine-related errors that can impact patient outcomes. In addition, several topics on this year's list reflect challenges that have arisen as a result of the stresses associated with delivering care during a global pandemic. -
Content ArticleA key part of healthcare digital transformation is the development and adoption of artificial intelligence technologies. This article, published in BMJ Health & Care Informatics, considers how human factors and ergonomic principles can be applied to the use of artificial intelligence in healthcare.
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Content ArticleA strong focus on systems thinking and an encouragement to apply insights and expertise from human factors and ergonomics is paramount in how we plan, design and deliver healthcare safely. It’s central to the WHO Global Patient Safety Action Plan, the NHS Patient Safety Strategy, new Patient Safety Incident Response Framework (PSIRF) guidance on how to investigate incidents of unsafe care and the National Patient Safety Syllabus.[1-3] It’s something Patient Safety Learning emphasise in our report A Blueprint for Action and is central to the organisational standards for patient safety that we’ve developed.[4] But how should we ‘do’ human factors? How do we apply the concepts, methodologies, tools and techniques in healthcare? What training do we need? How can patient safety managers embed human factors in all of their work, not just a reactive response to incidents of harm? These are some of the questions that patient safety managers have been asking and discussing in the recent Patient Safety Manager Network (PSMN) meetings. The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance, providing information, peer support and safe space for discussion. You can find out more about the network here.
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Content ArticleAdopting the principles and practices of human performance has led to valuable business and safety performance improvements in high-risk high-consequence industry sectors, such as energy and aviation. Eager to realise similar levels of improvement, several companies in the pharmaceutical and biopharmaceutical manufacturing sector have begun the adoption of human performance within their operations. However, the unique industry context and regulatory environment of this sector has proven the adoption of human performance principles and practices to be more challenging and complex than simply copying from the successes of other industries. In this webinar, you'll hear from industry professionals who will share their experiences and perspectives on human performance adoption value, successes and challenges.
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Content ArticleDebriefs (or After Action Reviews) are increasingly used in training and work environments as a means of learning from experience. Tannenbaum and Cerasoli assessed the efficacy of debriefs with a quantitative review and found organisations can improve individual and team performance by approximately 20% to 25% by using properly conducted debriefs.
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Content ArticleJulie Avery and Brian Edwards, Chartered Institute of Ergonomics and Human Factors, presented at the recent Human Error Forum. They share their presentation slides on human performance and organisational learning and how to integrate human performance into existing systems.
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Content ArticleHigh Reliability Organisations (HRO), including healthcare and aviation, have a common focus on risk management. The human element is a ‘weak link’ which may result in accidents or adverse events taking place. Surgeons and other healthcare professionals can learn from aviation's rigorous approach to the role of human factors (HF) in such events, and how we can minimise them. Air Accident Investigation Branch (AAIB) reports show that fatal accidents are frequently caused by pilots flying outside their own personal limits, those of the aircraft or environment. Similarly, patient morbidity or mortality may occur if surgeons work outside personal their capability, with poor procedure selection and patient optimisation, or with a team or theatre environment not suited to the procedure. The authors of this study introduce the personal limitations checklist – a tool adapted from aviation that allows surgeons to define their limits in advance of any decision to operate, and develop critical self-reflection. It also allows management of patient expectations, shared decision making, and flattening of team hierarchy. The minimum skills, patient characteristics, team and theatre resources for any given procedure to proceed are defined. If the surgeon is ‘out of limits’, redressing these factors, seeking additional assistance, or thorough patient consenting may be required for the safe conduct of the procedure. The authors explore external pressures that could cause a surgeon to exceed both personal and organisational limits.
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Content ArticleThe aim of this study from Mahadevan et al. was to understand human factors (HF) contributing to disturbances during invasive cardiac procedures, including frequency and nature of distractions, and assessment of operator workload. They observed 194 cardiac procedures in three adult cardiac catheterisation laboratories over 6 weeks. The study found that fewer than half of all procedures were completed without interruption/distraction. The majority were unnecessary and without relation to the case or list. The authors propose the introduction of a ‘sterile cockpit’ environment within catheter laboratories, as adapted from aviation and used in surgical operating theatres, to minimise non-emergent interruptions and disturbances, to improve operator conditions and overall patient safety.
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Content ArticleThe COVID-19 pandemic resulted in an unprecedented reduction in the delivery of surgical services worldwide, especially in non-urgent, non-cancer procedures. A prolonged period without operating (or ‘layoff period’) can result in surgeons experiencing skill fade (both technical and non-technical) and a loss of confidence. While senior surgeons in the UK may be General Medical Council (GMC) validated and capable of performing a procedure, a loss of ‘currency’ may increase the risk of error and intraoperative patient harm, particularly if unexpected or adverse events are encountered. Dual surgeon operating may mitigate risks to patient safety as surgeons regain currency while returning to non-urgent operating and may also be beneficial after the greatly reduced activity observed during the COVID-19 pandemic for low-volume complex operations. In addition, it could be a useful tool for annual appraisal, sharing updated surgical techniques and helping team cohesion. This paper explores lessons from aviation, a leading industry in human factors principles, for regaining surgical skills currency. We discuss real and perceived barriers to dual surgeon operating including finance, training, substantial patient waiting lists, and intraoperative power dynamics.
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Content ArticleIn 2002 the UK Department of Health and the Design Council jointly commissioned a scoping study to deliver ideas and practical recommendations for a design approach to reduce the risk of medical error and improve patient safety across the National Health Service (NHS). The research was undertaken by the Engineering Design Centre at the University of Cambridge, the Robens Institute for Health Ergonomics at the University of Surrey and the Helen Hamlyn Research Centre at the Royal College of Art. The research team employed diverse methods to gather evidence from literature, key stakeholders, and experts from within healthcare and other safety-critical industries in order to ascertain how the design of systems—equipment and other physical artefacts, working practices and information—could contribute to patient safety. Despite the multiplicity of activities and methodologies employed, what emerged from the research was a very consistent picture. This convergence pointed to the need to better understand the healthcare system, including the users of that system, as the context into which specific design solutions must be delivered. Without that broader understanding there can be no certainty that any single design will contribute to reducing medical error and the consequential cost thereof.
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Content ArticlePatient safety incidents (PSIs) are common and can lead to fatal outcomes. Effective investigation of PSIs is essential to optimise learning and take action to prevent further incidents occurring. The Yorkshire Contributory Factors Framework is a tool which has an evidence base for optimising learning and addressing causes of patient safety incidents by helping clinicians, risk managers and patient safety officers identify contributory factors of PSIs. Incidents that occur in a hospital setting have been well studied and all contributory factors have been mapped. Based on this research, a team of practicing clinicians with human factors experts has adapted the evidence to a pragmatic 2 page framework. The document suggests questions that you might want to ask of those involved in the incident. The underlying aim of this tool is not to ignore individual accountability for unsafe care, but to try to develop a more sophisticated understanding of the factors that cause incidents.
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Content Article
Improving diagnosis in health care (2015)
Patient-Safety-Learning posted an article in Diagnosis
This report from The National Academies of Sciences, Engineering and Medicine highlights three key themes around the issue of diagnostic error: The importance of diagnostic error in patient safety and the need to give the subject more research attention The central role that patients play in helping to avoid diagnostic error. The idea that diagnosis is a collaborative effort involving intra- and interprofessional teamwork. It also looks at several specific issues that must be addressed to reduce diagnostic errors. -
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WireSafe® is an innovative solution designed to prevent retained guidewires during central venous catheter (CVC) insertion. Retained guidewires are never events that require urgent removal if accidentally left in. They occur in about 1 in 300,000 procedures. We interviewed Maryanne, who developed the WireSafe®, on the innovation, the human factor considerations in designing it and the difficulties she faced getting a new product into the NHS. -
Content ArticleThis blog for the High Reliability Organizing website looks at the implications of 'preoccupation with failure' for individuals and organisations. The author highlights examples of how preoccupation with failure, as first described by Karl Weick and Kathleen Sutcliffe, can improve outcomes and reduce costs in healthcare organisations and in other sectors. She identifies barriers to organisations engaging with the process, including reluctance to look for 'hidden failures' and poor communication.
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