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Found 121 results
  1. Content Article
    Healthcare Safety Investigation Branch (HSIB) report on the inadvertent administration of an oral liquid medicine into a vein. This report indicated the importance of using human factors in the investigation process. The investigation reviewed the effectiveness of the current processes for the storage of medicines, equipment design, and the prescribing, preparation, checking and administration of medication. It also considered the contextual, environmental and human factors that influenced the inadvertent administration of an oral solution into a vein. The effectiveness of current processes for implementation of local safety standards for invasive procedures was also considered. A human factors expert was involved in the investigation and a dedicated report was written based on the evidence reviewed, a reconstruction of the event and a simulation of what should have happened.
  2. Content Article
    Five top tips from a Human Factors Advisor at Eastern AHSN for your organisation to consider to help improve human factors.
  3. Content Article
    This study from Petschonek et al. published in the Journal of Patient Safety sought to develop a survey that would measure individual perceptions of Just Culture in a hospital setting. The research team created a 27-item survey, which displayed adequate theoretical structure and internal reliability.
  4. Content Article
    Presentation by Andrew Brent (Sepsis Clinical Lead, Oxford AHSN & Oxford University Hospitals NHS Foundation Trust) and Bethan Page (Oxford AHSN) in collaboration with Dr Matt Inada-Kim (Wessex AHSN).
  5. Content Article
    The Royal College of General Practitioners (RCGP) have developed this toolkit to disseminate learning highlighted from acute kidney injury (AKI) case notes reviews, part of the RCGP AKI Quality Improvement project. Working with GP practices, they have put together resources, alongside national Think Kidneys guidance, to support the implementation of quality improvement methods into routine clinical practice.
  6. Content Article
    The Whole System Flow programme has been accepted for presentation at the International Conference of Integrated Care in San Sebastien in April 2019. This poster provides an overview of the programme’s structure and outputs. We will be opening applications in April for the next group of systems to work with on a system pathway that they choose.
  7. Content Article
    The response to COVID-19 has created an outstanding amount of change to the NHS and we must learn from this, says Samantha Machen, Improvement Facilitator at Central London Community Healthcare NHS Trust and PhD Improvement Fellow at the Health Foundation.
  8. Content Article
    As the number of COVID-19 hospital admissions gradually declines, policy attention is turning to how the NHS can restart some more routine activities. But doing this while living alongside COVID-19 will involve major practical challenges that will need to be overcome. This new discussion paper by Nigel Edwards looks at the realities the health and care systems will now begin to face.
  9. Content Article
    This is a comprehensive collection of proven quality, service improvement and redesign tools, theories and techniques that can be applied to a wide variety of situations. You can search the collection alphabetically for a specific tool or browse groups of tools using one of four categories.
  10. Content Article
    This study covers the world outlook for patient engagement solutions across more than 190 countries. For each year reported, estimates are given for the latent demand, or potential industry earnings (P.I.E.), for the country in question (in millions of U.S. dollars), the percent share the country is of the region, and of the globe. These comparative benchmarks allow the reader to quickly gauge a country vis-à-vis others. 
  11. Content Article
    In The Silo Effect, the author uses an anthropological lens to explore how individuals, teams and whole organisations often work in silos of thought, process and product. With examples drawn from a range of fascinating areas - the New York Fire Department and Facebook to the Bank of England and Sony - these narratives illustrate not just how foolishly people can behave when they are mastered by silos but also how the brightest institutions and individuals can master them.
  12. Content Article
    This short video, by Understanding Patient Data,  shows people talking about why it's important to use patient data, and why we need to better explain the benefits and safeguards.
  13. Content Article
    A short video to show you how to have a video consultation with your GP surgery after receiving an invitation via text message. 
  14. Content Article
    The CARe QI handbook is based on research in a range of healthcare organisations and settings, including acute care, primary care, care homes, oral health and community settings. It was designed to provide practical tools to apply ideas from resilient healthcare to quality improvement. 
  15. Content Article
    Using human factors science increases the likelihood of obtaining well-designed and easy to use products to deliver safe patient care. Poor designs, by contrast, can cause unintended harm to patients. This guide, developed by the Clinical Human Factors Group, is to help staff working in procurement or with medical devices and equipment, to use human factors to specify and select the best and safest products to use in healthcare. This is important because conformity with regulations and standards does not always guarantee safe outcomes when products are used in practice. This guide is particularly relevant to medical devices but can be used for other healthcare products. 
  16. Content Article
    I had been away from the hospital for a week and I was reluctant to go back in, fearful of what I would face, but I am amazed at how much has been achieved in 7 days.
  17. Content Article
    Design is a structured process for identifying problems and developing and evaluating user-focussed solutions. It has been successfully used to transform products, services, systems and even entire organisations. Based on the extensive experience of the aviation, military and nuclear industries, it is clear that effective design thinking can facilitate the delivery of products, services, processes and environments that are intuitive, simple to understand, simple to use, convenient, comfortable and consequently less likely to lead to error and accidents. Confusing, complex and unwieldy designs, which are all too often present in healthcare, are at best less effective than they could be. At worst, they are potentially dangerous to medical staff or the patient - or both. The contribution of design to improving safety in the context of medical systems is an area which remains relatively unexplored.  This scoping review is a joint report from the Robens Centre for Health Ergonomics at the University of Surrey; The Helen Hamlyn Research Centre at the Royal College of Art; and The Cambridge Engineering Design Centre at the University of Cambridge to identify how the effective use of design could help to reduce medical accidents.
  18. Content Article
    An examination of how humans interact with their environments and each other led this team to question one of its long-standing medication safety practices and change how they work.
  19. Content Article
    There are 15 Academic Health Science Networks (AHSNs) across England, established by NHS England in 2013 to spread innovation at pace and scale – improving health and generating economic growth. Each AHSN works across a distinct geography serving a different population in each region.
  20. Content Article
    The PReCePT Programme is a quality improvement project designed to reduce the incidence of cerebral palsy through the administration of magnesium sulphate to eligible preterm mothers across England.
  21. Content Article
    This toolkit supports the implementation of the Structured Judgement Review (SJR) process to effectively review the care received by patients who have died. This will allow learning and support the development of quality improvement initiatives when problems in care are identified. This toolkit also provides information and links to resources on change management and quality improvement methodologies.
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