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Showing results for tags 'Human factors'.
Found 547 results
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Content ArticleThis article by Lauren McGIll in The Walrus looks at how design changes to the trauma bay at St Michael's Hospital in Toronto are saving lives. Lack of intentional design in hospitals, new technologies and a culture that celebrates adaptability all contribute to what the author describes as "a piecemeal approach" to emergency medicine workspaces. The outcome of this is ultimately higher mortality rates as staff do not have an optimum working environment. The article describes a research project set up in 2015 by doctors Christopher Hicks and Andrew Petrosoniak, which aimed to identify and remove latent hazards and obstacles that cost trauma staff time in emergency situations. They redesigned the trauma bay at St Michael's hospital as a result of their findings, and early reports are that dramatic rescues have been possible thanks to the new layout. Petrosoniak says, “You cannot remove the stress of someone dying in front of you, but we can remove the stress of not being able to find equipment.” Further reading Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review (BMJ Quality & Safety) Study protocol for a framework analysis using video review to identify latent safety threats: trauma resuscitation using in situ simulation team training (TRUST) (BMJ Open) Stress Testing the Resuscitation Room: Latent Threats to Patient Safety Identified During Interprofessional In Situ Simulation in a Canadian Academic Emergency Department (AEM Education and Training) Health professionals' experience of teamwork education in acute hospital settings: a systematic review of qualitative literature (JBI Evidence Synthesis)
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Content ArticleThis cross-sectional study in BMJ Quality & Safety examines the association of hospital nursing skill mix with patient mortality and quality of care. The study analysed patient discharge data, hospital characteristics and nurse and patient survey data from adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland. The authors found that a bedside care workforce with a greater proportion of professional nurses is associated with better outcomes for patients and nurses. They suggest that having a higher proportion of assistive nursing personnel without professional nurse qualifications reduces the skill mix and may: contribute to preventable deaths erode quality and safety of hospital care contribute to hospital nurse shortages.
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Content ArticleThis webinar from the Chartered Institute of Ergonomics & Human Factors is about boosting organisational and personal performance by recognising, measuring and promoting wellness. It describes the development and application of indices to measure wellness using a 'Whole Life - Whole Organisation' approach. Topics include: Ways for organisations to improve key performance indicators such as sales, productivity, customer service, reduction in accidents, quality, safety/liability, people retention, absence, presenteeism and levels of engagement/motivation Access to new software and management intelligence to support and implement a 3D next generation organisational improvement approach New certifications such as Certificate in Personal Performance - Wellness Management Global Wellness Indices for Healthcare, Hybrid Workers, Hazardous Industries and Universities (staff and students) New research and development and the growing international community of organisations and people active in Performance – Wellness – Health
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Content Article
Prevention of Future Deaths report – Mary Land
Mark Hughes posted an article in Coroner reports
Mary Land was a patient on an Acute Respiratory care unit 'surge' ward at Pinderfield Hospital, being treated for COVID pneumonia against a backdrop of comorbidities. On 5 February 2021 she was discovered in an unresponsive condition, with the tube connecting her facemask to a BIPAP ventilator detached at the connection point to the mask. In his report, the Coroner raised patient safety concerns relating to how the tubes of her Philips Respironics AF 541 mask became detached from the ventilator. -
Content ArticleThis paper by Biophorum, a membership organisation for the biopharmaceutical industry, looks at how companies in the sector can adopt a human performance approach to operations. It highlights the need to move away from a focus on reducing human error and towards integrating fundamental systems changes that will enhance human performance.
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Content ArticleSerious Hazards of Transfusion (SHOT) introduced a new Human Factors Investigation Tool (HFIT) in 2021. The tool can be used to investigate and capture systemic as well as individual factors where there has been an error. This case study uses the updated Human Factors Investigation Tool and Systems Engineering Initiative for Patient Safety (SEIPS) framework to work through an ABO incompatible red cell transfusion case reported to SHOT.
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Content ArticleHuman performance is cited as a causal factor in the majority of aircraft accidents. This manual addressed various aspects of Human Factors and its impact on flight safety but many of the principles will be relevant to healthcare also.
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Content ArticleAn examination of how humans interact with their environments and each other led a team at Spectrum Health Helen DeVos Children’s Hospital in Grand Rapids, Michigan, USA, to question one of its long-standing medication safety practices and change how they work.
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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 ArticleOn 2 September 2006, all 14 crew of a UK Royal Air Force (RAF) ‘spy plane’ Nimrod XV230 were lost following a catastrophic mid-air fire. The aircraft was on a routine mission when a leak of aviation fuel, shortly after air-to-air refuelling, came into contact with a source of ignition. The fire was not accessible, not able to be remotely suppressed, and the incident was not survivable. ‘The Nimrod Review’, led by The Hon. Mr Justice Haddon-Cave, is a model investigation, and should be required reading for executives and leaders in all industries. The Review takes the aircraft fire as its starting point, but casts its net far and wide through the organisation, as well as considering relevant events in other industries. This Nimrod XV230 tragedy is so rich in lessons, Martin Anderson, Chartered Human Factors Professional, shares on his website a series of articles about the Nimrod XV230.
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Content ArticleThe Chartered Institute of Ergonomics & Human Factors (CIEHF) have published a new white paper intended to promote systems thinking among those who develop, regulate, procure, and use AI applications in healthcare, and to raise awareness of the role of people using or affected by AI.
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Content ArticleMany diagnostic mistakes are caused by reasoning errors, but lack of feedback makes it difficult for healthcare providers to make improvements in this area. This paper, published in BMJ Quality & Safety, describes the reason for and process of developing 'The Diagnosis Learning Cycle', a new model for feedback and improvement in diagnosis. The model is based on theory and knowledge from both outside and within the field of healthcare. It proposes a standardised feedback mechanism that includes concrete measures of factors such as reasoning and confidence.
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Content Article
Why investigate? Part 11: We have a situation
Graham Edgar posted an article in Why investigate? Blog series
In the latest blog in the 'Why investigate' blog series, Professor Graham Edgar discusses situational awareness. -
Content ArticleVarious research articles have reported that the science of Human Factors is of vital importance in improving human-machine systems. However, what is lacking is a fundamental historical outline of why Human Factors is important. This article from deWinter and Hancock provides such a foundation, using arguments ranging from pre-history to post-COVID.
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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 Article
CIEHF: COVID-19 human factor response
Patient Safety Learning posted an article in Guidance
The pandemic has brought human factors issues to prominence. The Chartered Institute of Ergonomics and Human Factors (CIEHF) and its members are responding rapidly to current challenges by providing expert guidance and help wherever it’s needed most. This site gives details and links to new guidance documents developed and published by us and matches human factors expertise to those needing assistance. -
Content ArticleCalls to integrate human factors and ergonomics (HFE) within healthcare and patient safety have become increasingly frequent in the last few years.This editorial from Waterson and Catchpole decscribes some of the misconceptions and misunderstandings that sometimes surround HFE.
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Content ArticleAs part of the Clinical Human Factors Group (CHFG)'s core mission to promote human factors science in education and training, CHFG have produced a series of E-learning modules for healthcare. These modules seek to encourage the positive actions that create patient safety that are relevant to all staff working in healthcare. We use a human factors and ergonomics perspective to show how human performance and safety are affected by the way we behave, communicate and interact at work. The learning is based around a true story re-created in a new film to show the complexity of how a patient safety incident develops in an everyday scenario. The actors illustrate the subtle behaviours, that we all do some of the time, that give rise to well-documented safety issues, as well as the safety-creating behaviours we want to encourage. The modules reflect items on the NHS England’s Patient Safety Syllabus.
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Content Article
"Am I safe?" Presented by Lee Fleisher (31 March 2021)
Patient Safety Learning posted an article in Good practice
“We have to create the culture of learning; the culture of having a safe space, the culture of wanting to do better and learning those conditions in which we do do better” This powerful talk looks directly at how a clear approach to patient safety really can improve the standard of care where you work. What is the culture of quality and safety that you’re trying to embed, can you actually do better? Learn why it’s important to focus on psychological safety; “if people start being scared, everyone gets scared then it expands”. Learn how an evidence based approach can allow us to tackle these issues rather than shy away from them; “what factors are maintaining safety? How do we get to good outcomes? What are the things working well? How do we understand human variation?”. Presented by Lee Fleisher, Emeritus Professor of Anesthesiology and Critical Care, University of Pennsylvania. -
Content ArticleMany adverse events arise from human factors, such as inefficient teamwork and communication failures, and the incidence of adverse events is greatest in the surgical area. Previous research has shown the effect of team training on patient safety culture and on different areas of teamwork. Limited research has investigated teamwork in surgical wards. The aim of this study, published in BMC Health Services Research, was to evaluate the professional and organizational outcomes of a team training intervention among healthcare professionals in a surgical ward after 6 and 12 months.
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Content ArticleThe Medicines and Healthcare products Regulatory Agency (MHRA) has published guidance on the importance of applying human factors to medical devices, so they are designed and optimised to minimise patient and user safety risks.
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Content ArticleThis guide from RSSB povides a practical illustration of how fatigue risks can be systematically managed to improve the health and safety of the workforce and operations. Although for the rail industry, it can be applied to other organisations. It sets out key elements of effective fatigue management and illustrates how these can be incorporated into a company's overarching safety management arrangements.
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Content ArticleVisual representation from Steven Shorrock on a quick way to evaluate where you can improve the flows of reporting within your organisation. The red highlights stronger influences.
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Content ArticleFrequent external interruptions and lack of collaboration among team members are known to be common barriers in end-of-shift handoffs between physicians in the emergency department. In spite of being the primary location for this crucial and cognitively demanding task, workstations are not designed to limit barriers and support handoffs. The purpose of this study from Joshi et al. was to examine handoff characteristics, actual and perceived interruptions, and perceived collaboration among emergency physicians performing end-of-shift handoffs in physician workstations with varying levels of enclosures—(a) open-plan workstation, (b) enclosed workstation, and (c) semi-open workstation. The study showed positive outcomes experienced by physician working in the enclosed workstation as compared to the open and semi-open workstations.
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Content Article
Absence of user-centric design: a threat to patient safety
Aditi Desai posted an article in Design for safety
Aditi Desai is a Consultant Obstetrician and Gynaecologist and has worked as a doctor in maternity and women's healthcare for the last 25 years. Having recently read the blog ‘Dangerous exclusions: The risk to patient safety of sex and gender bias‘, Aditi highlights how many aspects presented in the blog resonate with staff working in healthcare and other industries.
