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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.
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Content ArticleCHIRP was formed in 1982 as a result of a joint initiative between the Chief Scientific Officer Civil Aviation Authority (CAA), the Chief Medical Officer CAA and the Commandant Royal Air Force Institute of Aviation Medicine (IAM). The programme was based on the Aviation Safety Reporting System (ASRS) that had been formed in the United States of America in 1976 under the management of National Aeronautical and Space Administration (NASA).
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Content ArticleCommercial aviation practices, including the role of the pilot monitoring, the sterile flight deck rule, and computerised checklists, have direct applicability to anaesthesia care. Checklists are commonly used in the operating room, especially the World Health Organization surgical safety checklist. However, the use of aviation-style computerised checklists offers additional benefits. In this editorial, Jelacic et al. discuss how these commercial aviation practices may be applied in the operating room.
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Have you ever stopped and considered what the link is between the Patient Safety Incident Response Framework (PSIRF) and Hollywood? Probably not. Most likely, you have spent the summer of 2023 immersed in your organisation’s transition from the Serious Incident Framework (SIF) to PSIRF. Outside work, for those of us who are cinema-goers, our main Hollywood-related dilemma has revolved around which to watch first, Barbie or Oppenheimer? At the end of April 2023, we were offered the opportunity to present at the Health Care Plus conference, held at the EXCEL centre in London. Ours was the graveyard slot: Day 2 of the conference; 3.15 pm. The time when, quite understandably, the conference participants attentional capacity is usually waning. How could we encourage participants to stay the distance? How do you make a graveyard slot at the end of a two-day conference engaging? More importantly, how do you rise to that challenge when the topic is implementing PSIRF? Our solution? Bring in Hollywood. Make PSIRF glamorous. Our blog shares what we presented: ‘PSIRF: The Hollywood Edit'. Unifying key messages from NHS England’s PSIRF guidance (NHS England, August 2022) with Hollywood movie titles and a bit of what we have learnt and reflected on along the way.- Posted
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Content ArticleIn this podcast for World Patient Safety Day, NHS England speaks to John, who was previously extensively involved in the safe design and operation of hazardous chemical plants and has a passion for human factors and safety culture. John shares his insights on why it is so important for patients and families to be listened to, and details of his experience in supporting the NHS to improve safety.
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Content ArticleIn rare cases, healthcare providers who have contributed to accidental patient harm may be criminally prosecuted to obtain justice for the patient and family or to set an example, which theoretically prevents other providers from making similar mistakes due to fear of punishment. This strategy was chosen in the recent case of RaDonda Vaught, who was convicted of criminally negligent homicide and impaired adult abuse after a medication error killed a patient in 2017. This article in the journal Human Factors in Healthcare discusses the case and its ramifications for healthcare staff and systems. The authors provide recommendations for actions that healthcare organisations should take to foster a safer and more resilient healthcare system, including: placing an emphasis on just culture. ensuring timely, systems-level investigations of all incidents. refining and bolstering participation in national reporting systems. incorporating Human Factors professionals at multiple levels of organisations. establishing a national safety board for medicine in the US.
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Content ArticleIn this article in the Irish Times, Niall discusses his book, Oops! Why Things Go Wrong, and explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, and most importantly, what we can do about it. You can also listen to an interview with Niall on BBC Radio Ulster’s Talkback (Listen from 38 mins to 57 mins). Related reading on the hub: Oops! Why things go wrong – a blog by Niall Downey
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News Article
Family welcomes new guidance to prevent breathing tube deaths
Patient Safety Learning posted a news article in News
A grieving family has welcomed new guidance to try to prevent a common surgical procedure from going wrong and causing deaths. Oesophageal intubation occurs when a breathing tube is placed into the oesophagus, the tube leading to the stomach, instead of the trachea, the tube leading to the windpipe. It can lead to brain damage or death if not spotted promptly. Glenda Logsdail died at Milton Keynes University Hospital in 2020 after a breathing tube was accidentally inserted into her oesophagus. The 60-year-old radiographer was being prepared for an appendicitis operation when the error occurred. Her family welcomed the guidance, saying in a statement: “We miss her terribly but we know that she’d be happy that something good will come from her tragic death and that nobody else will go through what we’ve had to go through as a family." Oesophageal intubation can occur for a number of reasons including technical difficulties, clinician inexperience, movement of the tube or “distorted anatomy”. The mistake is relatively common but usually detected quickly with no resulting harm. The new guidance, published in the journal Anaesthesia, recommends that exhaled carbon dioxide monitoring and pulse oximetry – which measures oxygen levels in the blood – should be available and used for all procedures that require a breathing tube. Experts from the UK and Australia also recommended the use of a video-laryngoscope – an intubation device fitted with a video camera to improve the view – when a breathing tube is being inserted. Read full story Source: The Independent,18 August 2022 -
News Article
World first in hologram patients
Patient Safety Learning posted a news article in News
Medical students are using hologram patients to hone their skills with life-like training scenarios. The project at Addenbrooke’s Hospital in Cambridge is the first in the world to use the mixed reality technology in this way. Students wear Microsoft HoloLens headsets that let them interact with the patient while still being able to see each other. Lecturers are able to alter the patient’s response, make observations and add complications to the scenario. It enables realistic and immersive safe-to-fail training which can be delivered remotely as well as in person. The first module, covering respiratory conditions and emergencies, has already been launched and more are planned around cardiology and neurology. The HoloScenarios system is being developed by Cambridge University Hospitals NHS Foundation Trust, in partnership with the University of Cambridge and US-based tech firm GigXR. Consultant anaesthetist Dr Arun Gupta, who is leading the project in Cambridge, said: “Mixed reality is increasingly recognised as a useful method of simulator training. As institutions scale procurement, the demand for platforms that offer utility and ease of mixed reality learning management is rapidly expanding" Read full story Source: CIEHF, 21 July 2022 -
News Article
Medical expert witnesses ‘should not scapegoat doctors’
Patient Safety Learning posted a news article in News
Medical experts in cases involving doctors should have a mandatory duty to consider systems issues such as inadequate staffing levels to avoid them being scapegoated for wider failures, the Medical Protection Society (MPS) has said. The MPS, which supports the the professional interests of more than 300,000 healthcare professionals around the world, says medical expert reports focus on scrutinising the actions of the individual doctor even when failings are a result of the setting in which they work. Its report on the issue, shared with the Guardian before publication, points out that for doctors “adverse opinion can lead to loss of career or liberty”. It references the case of Dr Hadiza Bawa-Garba who was convicted of gross negligence manslaughter in 2015 and handed a 24-month suspended sentence for her part in the death of six-year-old Jack Adcock from sepsis. She was later struck off by the General Medical Council before the court of appeal overturned the GMC’s decision. Dr Rob Hendry, the MPS medical director, said: “In giving an opinion on whether or not the care provided by a doctor has fallen short of a reasonable standard, it would seem fair to the doctor that the medical expert considers all relevant circumstances. Any individual performance concerns must of course be addressed, but doctors should not be scapegoats for the failings of the settings in which they work. Sadly, we see this all too often in cases against doctors … “Many expert reports focus solely on the actions of the individual without considering the wider context. In reality, patient harm arising from medical error is rarely attributable to the actions of a single individual. Inadequate staffing levels, lack of resources, or faulty IT systems are just some issues which can contribute to adverse incidents. Doctors confront these issues every day and have little influence over them.” Read full story Source: The Guardian, 18 July 2022 -
News Article
Hospitals urged to offer patients more gown sizes
Patient Safety Learning posted a news article in News
Hospitals are being asked to offer a wider range of gown sizes to better protect patients' dignity. It follows the experience of a patient from Wiltshire who said she was offered a gown that was "far too small" during a hospital stay in Bristol. Barbara Gale said it gaped at the back and made her feel "embarrassed". The experience sparked calls for more sizing options.. An independent study conducted by the University of Strathclyde in Glasgow in 2019 asked patients across the UK for their thoughts on the issue of hospital gowns. Consultant clinical psychologist for the NHS, Nicola Cogan, led the research and said the findings showed Ms Gale's experience was not an isolated case. She said: "We spoke to a 1,000 patients and found over two thirds reported they struggled to get a gown on themselves and 70% reported the gown did not fit". "It's not cost effective for the NHS, but also it shows that the gown is currently not fit for purpose." Read full story Source: BBC News, 13 March 2023 -
Content ArticleThis download is the third of three chapters of a book which complements the Chartered Institute of Ergonomics and Human Factors' Healthcare Learning Pathway and is intended as a practical resource for students The book aims to provide well-founded, practical guidance to those responsible for leading and implementing human factors programmes and interventions in health and social care.
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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. Rob talks to us about his passion for using human factors to improve safety in emergency departments, how allowing doctors to choose their own shifts can make staffing safer and how better integrating technology could help doctors diagnose and treat patients more safely and effectively. -
Content ArticleA significant amount of professional time is wasted during a medical ward round retrieving patient notes from the ward trolley. If the efficiency of this non-clinical, non-functional interaction could be improved it would save time, maintain continuity and have financial implications. One identified constraint was the structure of the traditional ward trolley; a stationary filing tray with vertical sleeves. During ward round, time is spent returning and retrieving each patients notes from outside the patient bay and additional time may be wasted if the notes are misplaced or in use elsewhere. To resolve this, the ‘Vista 90’ trolley with horizontal, transparent trays, is portable and has an ergonomic writing surface was selected as a potential second generation replacement. An assessment of the impact of the Vista 90 trolley over the traditional trolley in the clinical setting was carried out on Erringham (medical) Ward, Worthing Hospital, West Sussex Hospital Trust, UK. This was by way of qualitative analysis performed by semi-structured interview of 12 doctors and other healthcare professionals who regularly interacted with the Vista 90 and traditional trolley in December 2012. The audit found that those interviewed preferred using the Vista 90 trolley over its predecessor as it improved the efficiency of the ward round and subsequent clinical work. It’s mobility allowed it to be easily transported with the ward round, reducing disruption during a consultation and between consecutives ones. The ergonomic writing surface was noted to improve legibility of documentation due to greater comfort and if placed appropriately, did not interfere with the doctor-patient interaction. The financial savings of this greater efficiency was found to be of significance and justify the cost of the Vista 90 within two weeks.
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Content ArticleIn this episode of The Human Risk podcast, host Christian Hunt speaks to Dr Gordon Caldwell, a retired NHS Consultant and Clinical Lead about the impact of medical bureaucracy. In 2019, Gordon had a photograph taken of himself lying next to a long line of forms, to highlight the amount of paperwork healthcare professionals need to fill in. Gordon is a campaigner against bureaucracy, and he wanted to make the point that time spent filling in forms is time spent not looking after patients. In the podcast, Christian and Gordon discuss: the genesis of the photograph and why Gordon felt motivated to take it the reasons why there is so much bureaucracy within the NHS the impact this has on patient care what Gordon sees as ways to improve it. See also: The Spectator: The NHS is drowning in paperwork Pictured: Doctor shows army of ‘pointless’ forms burying NHS hospitals
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Content ArticleThere is little longitudinal information about the type and frequency of harm resulting from medication errors among outpatient children with cancer. This study aimed to characterise rates and types of medication errors and harm to outpatient children with leukaemia and lymphoma over 7 months of treatment.
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Content Article
‘Human factors’ is the science of improving performance by understanding individual or team behaviour and cognitive biases. This can allow a redesign of clinical systems and environments to improve patient safety. This course aims to help healthcare professionals understand human factors in complex healthcare setting and can be delivered as a full day, half day or a conference talk. It was developed by Professor Robert Galloway, Emergency Medicine Consultant at University Hospitals Sussex NHS Trust. The course covers: the principles of ‘human factors’–why errors occur. human cognitive biases (in memory, reasoning, decision-making). practical skills and tools to improve individual/team performance and patient safety. You can email Rob Galloway for more information on booking this course. -
Content ArticleThese prompt cards were developed by a team at University Hospitals Sussex NHS Foundation Trust to assist emergency department teams in dealing with: medical emergencies trauma transfers and briefings anaesthetics and resuscitation procedures medications clinical scores.
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Content ArticleThis paper aims to highlight how to reduce medication errors through the implementation of human factors science to the design features of medication containers. Despite efforts to employ automation for increased safety and decreased workload, medication administration in hospital wards is still heavily dependent on human operators (pharmacists, nurses, physicians, etc.). Improving this multi-step process requires its being studied and designed as an interface in a complex socio-technical system. Human factors engineering, also known as ergonomics, involves designing socio-technical systems to improve overall system performance, and reduces the risk of system, and in particular, operator, failures. The incorporation of human factors principles into the design of the work environment and tools that are in use during medication administration could improve this process. During periods of high workload, the cognitive effort necessary to work through a very demanding process may overwhelm even expert operators. In such conditions, the entire system should facilitate the human operator’s high level of performance. Regarding medications, clinicians should be provided with as many perceptual cues as possible to facilitate medication identification. Neglecting the shape of the container as one of the features that differentiates between classes of medications is a lost opportunity to use a helpful characteristic, and medication administration failures that happen in the absence of such intentional design arise from “designer error” rather than “user error”. Guidelines that define a container’s shape for each class of medication would compel pharmaceutical manufacturers to be compatible and would eliminate the confusion that arises when a hospital changes the supplier of a given medication.
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Content ArticleIn this blog, published by What's The Pont, the author provides a summary of the The Swiss Cheese Model of Accident Causation, developed by Professor James T. Reason, and looks at what it means for learning from failure. Related reading: The Swiss cheese respiratory virus pandemic defence Reverse Swiss Cheese – Driving safety culture from the blunt end (24 June 2022) Good and bad reasons: The Swiss cheese model and its critics (June 2020)
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Content ArticleHealthcare relies on high levels of human performance; however, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. This narrative review in the journal Anaesthesia aims to describe what is known about human factors in anaesthesia to date.
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Content ArticleEurocontrol’s HindSight magazine is a magazine on human and organisational factors in operations, in air traffic management and beyond. This issue is on the theme of Handling Surprises: Tales of the Unexpected. You will find a diverse selection of articles from frontline staff, senior managers, and specialists in operations, human factors, safety, and resilience engineering in the context of aviation, healthcare, maritime and web operations. The articles reflect surprise handling by individuals, teams and organisations from the perspectives of personal experience, theory, research and training.
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Content ArticleThe Chartered Institute of Ergonomics and Human Factors (CIEHF) have put together this short video to give you an idea of where to start when asked the question of what ergonomics is.
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Content ArticleIt is difficult to monitor compliance to surgical checklists, which is associated with improved patient outcomes. This research study in The Annals of Surgery reported for the first time on the use of the Operating Room Black Box (ORBB) to track checklist compliance, engagement, and quality. The authors took a retrospective review of prospectively collected ORBB data and measures of checklist compliance, engagement and quality were assessed. ORBB provides the unprecedented ability to assess not only compliance with surgical safety checklists but also engagement and quality. This technology allows the assessment of compliance in near real time and to accurately address safety threats that may arise from noncompliance.
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Content ArticleMusculoskeletal disorders (MSDs) are one of the main causes of ill health in the workplace, leaving many employees with painful long-term injuries. Health and social care are industries with a particularly high incidence of MSDs among staff. This infographic by the Chartered Institute for Ergonomics and Human Factors (CIEHF) lists the warning signs to be aware of and gives lots of easy-to-follow practical advice on how to prevent or reduce the risk of developing symptoms. There’s also a link to find exercises that could help prevent injuries occurring.
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