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Showing results for tags 'Human factors'.
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News ArticleLoughborough University is collaborating with NHS England to deliver learning to hundreds of healthcare professionals in a bid to improve patient safety. Human factors and ergonomics experts in the School of Design and Creative Arts will deliver Levels 3 and 4 of the NHS Patient Safety Syllabus and Curriculum after winning a competitive tender process. Under the leadership of Dr Mike Fray, supported by Professor Sue Hignett and Professor Thomas Jun, the Loughborough University team will craft and deliver educational content to 820 patient safety specialists across various NHS Trusts in England from 2023 to 2024. In 2021, the NHS Patient Safety Syllabus was created by drawing upon best practice from a number of safety-critical industries. It has as a core aim of changing how staff think about improving patient safety. The key to this is switching the focus to proactive prevention of safety incidents, and away from the current largely retrospective analyses. Dr Fray believes Loughborough University’s world-leading reputation in the delivery of human factors and ergonomics education will help the NHS achieve its goals. Dr Fray said: “No healthcare worker goes to work thinking they will do harm, but the systems, processes and complexity of the work can lead to errors, omissions, or reductions in quality of care. “With this new course we will be able to support patient safety specialists in each Trust to lead safety improvement work and provide safety science expertise to their organisations so that patients across the NHS can benefit.” Aidan Fowler, National Director of Patient Safety said: ‘’Training and education is at the centre of the NHS Patient Safety Strategy so that we can empower people with the latest skills and knowledge in patient safety science. “The launch of this training for our patient safety specialists is the latest development in this work, using the syllabus created with the Academy of Medical Royal Colleges and adding to the training already available to all staff in the NHS.” Read full story Source: Loughborough University, 15 November 2023
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Content ArticleAmbulatory infusion pumps are small, battery powered devices that allow patients to carry out day-to-day activities while receiving medication. They are used for many healthcare needs, including symptom relief during palliative care, and in different settings including hospitals, hospices and patients’ homes. Despite having audio and visual warning alarms to notify when medication is not being delivered as it should be, there is a risk that alarms can go unnoticed, particularly by healthcare staff in inpatient settings. The patient case in the Health Services Safety Investigations Body (HSSIB) investigation report is Stephen, a 45-year-old cancer patient on palliative care in hospital, who did not receive his pain relief medication for six hours. Over the course of six hours, there were eight warnings.
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Content ArticleIn this article, Stephen Shorrock, Chartered Ergonomist and human factors specialist, shares some some insights on the concept of ‘human error and the idea of ‘honest mistakes’. He outlines the problem with thinking of errors as ‘causing’ unwanted events such as accidents, arguing that this approach ignores all of the other relevant ‘causes’, especially in high-hazard, safety-critical systems,
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Content ArticleThis article in the British Journal of Anaesthesia argues that the criminalisation of medical accidents leaves clinicians scared to report systemic causes and contributors to bad outcomes, removing a foundational pillar of patient safety. Looking at the case of RaDonda Vaught, a nurse who was found guilty of criminally negligent homicide for a fatal medication accident, the authors highlight the need to move away from seeing adverse incidents in healthcare as being easily avoided through greater attention, trying harder or adherence to rules. They call on healthcare organisations to learn from the case and argue that healthcare systems need to be collaboratively redesigned with a systems perspective.
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Content ArticleTo improve the safety and quality of healthcare, we try to understand and improve how healthcare providers accomplish patient care "work." This work includes synthesising information from a patient's history and physical examination or from a handoff, performing tests or procedures, administering medications and providing information so that patients can make the best choices for themselves. Sometimes this work flows very well and everyone is pleased with the results, but sometimes this work does not unfold in the way that was anticipated. This article, originally published in Pennsylvania Patient Safety Advisory, argues that efforts to improve healthcare work will not succeed without recognising that there is a difference between a theoretical construct of "work-as-imagined" and the reality of "work-as-done".
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Content ArticleStephen Shorrock looks at how we use deficit-based taxonomies when describing incidents in healthcare and why neutralised taxonomies may be more flexible and useful.
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News Article
Collective intelligence can help reduce medical misdiagnoses
Patient Safety Learning posted a news article in News
An estimated 250,000 people die from preventable medical errors in the U.S. each year. Many of these errors originate during the diagnostic process. A powerful way to increase diagnostic accuracy is to combine the diagnoses of multiple diagnosticians into a collective solution. However, there has been a dearth of methods for aggregating independent diagnoses in general medical diagnostics. Researchers from the Max Planck Institute for Human Development, the Institute for Cognitive Sciences and Technologies (ISTC), and the Norwegian University of Science and Technology have therefore introduced a fully automated solution using knowledge engineering methods. The researchers tested their solution on 1,333 medical cases provided by The Human Diagnosis Project (Human Dx), each of which was independently diagnosed by 10 diagnosticians. The collective solution substantially increased diagnostic accuracy: Single diagnosticians achieved 46% accuracy, whereas pooling the decisions of 10 diagnosticians increased accuracy to 76%. Improvements occurred across medical specialties, chief complaints, and diagnosticians’ tenure levels. "Our results show the life-saving potential of tapping into the collective intelligence," says first author Ralf Kurvers. He is a senior research scientist at the Center for Adaptive Rationality of the Max Planck Institute for Human Development and his research focuses on social and collective decision making in humans and animals. Read full story Source: Digital Health News, 2 November 2023 -
Content ArticleThe depleting effect of repeated decision making is often referred to as decision fatigue. Understanding how decision fatigue affects medical decision making is important for achieving both efficiency and fairness in health care. In this study, Persson et al. investigate the potential role of decision fatigue in orthopaedic surgeons' decisions to operate, exploiting a natural experiment whereby patient allocation to time slots is plausibly randomised at the level of the patient. The results show that patients who met a surgeon toward the end of his or her work shift were 33 percentage points less likely to be scheduled for an operation compared with those who were seen first. In a logistic regression with doctor-fixed effects and standard errors clustered at the level of the doctor, the odds of operation were estimated to decrease by 10.5% for each additional patient appointment in the doctors' work shift. This pattern in surgeons' decision making is consistent with decision fatigue. Because long shifts are common in medicine, the effect of decision fatigue could be substantial and may have important implications for patient outcomes.
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Content ArticleIn this article, published by Psychology Today, Eva Krockow looks at research questioning the notion that we can run out of willpower. Key points:Decision fatigue describes a depletion of choice quality with repeated decision-making.Previous studies suggested people make poorer choices late in the day, possibly affecting healthcare outcomes.Recent findings question the existence of decision fatigue and suggest a self-fulfilling prophecy.Read the full article via the link below.
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Content ArticleSteven Shorrock begins this editorial, published by Hindsight, by explaining what he means by work-as-judged: "We all have a habit that we are hardly even aware of; we judge others’ work performance, every day, throughout the day. Whether it’s the work of people in other organisations, in other parts of our organisation, in our own immediate work environment, when driving home, or at home, we evaluate, appraise and judge others’ performance. We don’t pay much attention to how we judge, but we ask ourselves all sorts of questions: “Did they do a good job?” “Did they work with due care and attention?” “Would I have done that?” I call this ‘work-as-judged’,and it has several characteristics that we should bear in mind." Read the full article via the link below.
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Content ArticleThe Safe & Sound podcast by the Royal College of Surgeons in Ireland explores the world of human factors in healthcare and patient safety. Each episode, we will try to untangle different aspects of this complicated web of human factors in healthcare, through interviews with some extraordinary guests and faculty in Ireland, and across the world.
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Content ArticleThis research report by the Energy Institute is intended for senior management and specialists charged with designing and implementing indicators for major accident hazards safety, or responsible for operating such systems. The report provides an introduction to the Health and Safety Executive (HSE) human factors key topics, and proposes ways in which these might be measured. It also sets out a process for identifying relevant PIs. The research report incorporates findings related to current thinking on safety PIs, in particular for human factors, how organisations currently monitor human factors in practice, and what processes are used to ensure appropriate indicators are selected.
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Content Article
Medication errors are a leading cause of patient harm globally. WHO launched the Global Patient Safety Challenge: Medication Without Harm, with the objective of preventing severe medication related patient harm globally. This publication is one of the documents in the WHO Technical Series on “Medication Safety Solutions” that the WHO is publishing, to address important aspects pertaining to medication safety. -
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. Tracey talks to us about how her love of applying psychology led to her role in patient safety, the importance of putting users at the centre of developing the Patient Safety Incident Response Framework (PSIRF), and what we can learn from magicians about patient safety.- Posted
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Content ArticleIn this article for the Journal of Patient Safety, Alan Card from the Department of Pediatrics at the University of California, argues that the purpose of patient safety work is to reduce avoidable patient harm, and this requires us to slay dragons—to eliminate or at least mitigate risks to patients. He expresses the view that current practice focuses almost exclusively on investigating dragons—tracking reports on the number and type of dragons that appear, how many villagers they eat and where, whether they live in caves or forests and so on. He argues that while information about risks is useful to the extent that it informs effective action, it does nothing to make patients safer by itself: "We cannot investigate a dragon to death. No more can we risk assess our way to safer care."
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Content Article
Simulation for non-pedagogical purposes has begun to emerge. Examples include quality improvement initiatives, testing and evaluating of new interventions, the co-designing of new models of care, the exploration of human and organisational behaviour, comparing of different sectors and the identification of latent safety threats. However, the literature related to these types of simulation is scattered across different disciplines and has many different associated terms, thus making it difficult to advance the field in both recognition and understanding. This paper, therefore, aims to enhance and formalise this growing field by generating a clear set of terms and definitions through a concept taxonomy of the literature. -
Content ArticleThis paywalled article, published in Advanced Critical Care, notes that ten years after the publication of a landmark article in AACN Advanced Critical Care, alarm fatigue continues to be an issue that researchers, clinicians, and organisations aim to remediate.
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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. Ashley talks to us about the need to professionalise patient safety roles while also upskilling frontline healthcare staff to improve patient safety, describing the role that professional coaching can play. He also discusses the challenges we face in understanding how AI affects decision making in healthcare and how it could contribute to patient safety incidents. -
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Patient and public involvement (PPI) is, these days, a given in healthcare policy and practice. Providers, commissioners, policymakers and researchers all state the importance of hearing from service users about what matters to them. This "involvement imperative" has given rise to a plethora of guidance notes, checklists, frameworks and toolkits, all purporting to show what good practice in PPI looks like. The Patient Experience Library decided to carry out a mapping exercise, to see how much guidance there is, and to see if they could make sense of it all. -
Content ArticleThis issue of Hindsight is on the theme of Just Culture…Revisited. The articles reflect Just Culture at the corporate and judicial levels from the perspectives of personal experience, professional practice, theory, research, regulation, and law. You will find a diverse set of articles from a diverse set of authors in the context of aviation, maritime, rail and healthcare. What is ‘just’? How should we conceptualise Just Culture? How should we design and implement regulations, policies and protocols relating to Just Culture? What gets in the way of Just Culture? In this issue, leading voices from the ground and air share perspectives on these questions.
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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. 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. This masterclass will focus on risk and behaviour to improve patient safety. Key learning objectives: Evaluating risk Using mapping techniques Safety interventions Behaviour Assessing safety culture. Register hub members receive a 20% discount. Email info@pslhub.org for a discount code.
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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. 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. This masterclass will focus on non-technical skills to improve patient safety. Key learning objectives: Task analysis Cognitive overload Reliability Non-technical skills Examples Register hub members receive 20% discount. Email info@pslhub.org for discount code.
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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. Key learning objectives: Understand the new patient safety landscape Understand the need for proportionality of investigation Learn how to use a range of techniques for conducting PSIIs Understand how to write an impactful improvement plan Consider how your current approach to patient safety investigations compares to the agreed national standards Understand typical pitfalls and traps associated with this wider work stream and tips for avoiding them. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. They have also authored articles on significant event analysis and clinical audit/quality improvement, all techniques seen as increasingly relevant to improving patient safety. Register hub members receive a 20% discount. Email info@pslhub.org for the discount code.
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EventAimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process and safety. There will be an extended focus on the role of human factors in patient safety investigation in line with the new National Patient Safety Incident Response Framework (PSIRF). For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/human-factors-in-healthcare or email kate@hc-uk.org.uk Follow this conference on Twitter @HCUK_Clare #HumanFactors hub members receive a 20% discount. Email info@pslhub.org for discount code.
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Content ArticleThis is the recording of a presentation given by Niall Downey at a recent Patient Safety Management Network (PSMN) meeting. Niall considered why error is inevitable, how it affects many different industries and areas of society and, most importantly, what we can do about it.
