Search the hub
Showing results for tags 'System safety'.
Found 518 results
-
Content ArticleIn this report the Professional Standards Authority for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care. It puts forward a number of recommendations to ensure safer care for all, with its main recommendation being that an independent Health and Social Care Safety Commissioner should be appointed for each UK country to identify current, emerging and potential risks across the whole health and social care system, and bring about the necessary action across organisations.
-
Content ArticleHealth information technology (health IT) has potential to improve patient safety, but its implementation and use has had unintended consequences and has raised new safety concerns. This viewpoint article in BMJ Quality & Safety introduces a new framework—the health IT safety (HITS) framework—to provide a conceptual foundation for health IT-related patient safety measurement, monitoring and improvement.
-
Content ArticleThe results of NHS Providers’ annual survey on regulation offer a strong endorsement of the change in approach that regulators’ are trying to make to reflect a new context of system – but the survey also reflects the fact that trusts’ experience of regulation over the past year still doesn’t match the vision the national bodies have set out. In this HSJ article, Mariya Stamenova emphasises the importance of implementing regulations to ensure systematic and efficient functioning within the NHS Framework.
-
Content ArticleNon-ventilator-associated hospital-acquired pneumonia (NVHAP) is one of the most common and deadly healthcare-associated infections, but it is not tracked, reported or actively prevented by most hospitals. This article in the journal Infection Control & Hospital Epidemiology highlights a national call to action to address NVHAP in the US. This national call to action includes: launching a national healthcare conversation about NVHAP prevention. adding NVHAP prevention measures to education for patients, healthcare professionals, and students. challenging healthcare systems and insurers to implement and support NVHAP prevention. encouraging researchers to develop new strategies for NVHAP surveillance and prevention.
-
Content ArticleWhen hospital patients do not have their teeth brushed it can lead to them developing pneumonia—poor dental hygiene in hospital is believed to be a leading cause of hundreds of thousands of cases of pneumonia a year. In this blog for Medscape, reporter Brett Kelman looks at the link between dental hygiene and hospital-acquired pneumonia, which kills up to 30% of patients who are infected with it. He highlights a lack of understanding of the impact of failing to brush inpatients' teeth, in spite of a growing body of research evidence that links lack of adequate toothbrushing to pneumonia infection.
-
Content ArticleThis decriptive study in BMC Health Services Research aimed to increase understanding of how patient and family education affects the prevention of medical errors, and provide basic data for developing educational content. The authors surveyed patients, families and Patient Safety Officers to investigate the relationship between educational approaches and medical error prevention. Participants thought that educational contents developed through this study could prevent medical errors. The results of this study are expected to provide basic data for national patient safety campaigns and standardised educational content development to prevent medical errors.
-
EventuntilAfter two years with virtual workshops due to the Covid-19 pandemic, we are pleased to announce that the fifth International Workshop on Safety-II in Practice will be organised on site in Edinburgh, Scotland on September 7-9, 2022. The Workshop is organised by FRAMsynt. The workshop will begin with an optional half-day tutorial on Safety-II in Practice in the afternoon of September 7 (1330-1730 BST), and continue with two days of meetings and discussions from September 8 (0830-1700 BST) to September 9 (0830-1500 BST). There will be a walking tour of Edinburgh old town (hosted by Steven Shorrock) and a dinner on the evening of September 8 for those who wish to join. Aim of the workshop The aim of the workshop is to share experiences from existing and/or planned applications of a Safety-II approach in various industries and practices. The workshop will give the participants an opportunity to present and discuss problems encountered and lessons learned – good as well as bad, practical as well as methodological. The workshop is a unique opportunity for safety professionals and researchers to interact with like-minded colleagues, to debate the strengths and weaknesses of a Safety-II approach, and to share ideas for further developments. The guiding principle for the workshop is “long discussions interrupted by short presentations”. In order to achieve this, the number of participants will be limited to 60 – first come, first served. Participation The workshop is open to everyone regardless of their level of experience with Safety-II. It will address the use of Safety-II in a variety of fields and for purposes ranging from investigations, performance analyses, organisational management and development, individual and organisational learning, and resilience. The workshop will provide a unique opportunity to: Discuss and exchange experiences on how a Safety-II approach can be used to analyse and manage complex socio-technical systems. Receive feedback on and support for your own Safety-II projects and ideas. Learn about the latest developments and application areas of Safety-II. Develop a perspective on the long-term potential of a Safety-II approach. Discussion topics, presentations and papers You can contribute actively to the workshop by submitting proposals for: Topics or themes for panel discussions (preferably with a presentation or introduction, but open suggestions of themes are also welcome). Presentations of ongoing or already completed work in industry and/or academia. Ideas that you would like to get a second opinion on. Questions or issues that you have been wondering about and would like to hear more about. The relevance of a Safety-II perspective for individual and organisational learning. The strategic management of Safety-II: how to introduce changes to routines and daily practice. For each type of proposal, please provide a short abstract (about 100 – 200 words, but even less if need be) with a summary of what you would like to present or discuss and how you want to be involved. All proposals will be reviewed and comments to the submitters will be provided. Please submit your proposed contribution to: contact@humanisticsystems.com Register
-
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. Soojin talks to us about how her personal experience of harm motivated her to work in healthcare and campaign for patient safety, the power of collaboration in improving healthcare safety and how healthcare workers can take steps to improve their own patient interactions. -
Content ArticlePresentation from Professor Mark Brinell, Vice Chair and Global Healthcare Expert at KMPG, on lessons we can learn from integrated care systems across the globe.
-
Content ArticleSafety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organsation. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value.
-
Content ArticleEarlier this year in March, a nurse from Vanderbilt University, RaDonda Vaught, was found guilty of criminally negligent homicide and gross neglect of a patient. In 2017, Vaught gave 75-year-old Charlene Murphey the incorrect medication. Murphey died as a result. Charlene Murphey’s tragic death highlights the failures of healthcare organisations and their leadership to be trustworthy as well as a fractured and weakened accountability system for patient safety in the United States.
-
Content ArticleIn basic terms, a safety management system (SMS) is a formal arrangement for managing, assuring, and improving safety. An SMS is not a single document, it is a framework for managing all risks that arise from running a transport system. It defines roles and responsibilities, sets arrangements for safety mechanisms, involves workers in the process, and ensures continuous improvement. The Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS) introduced the requirement for and content of an SMS. The regulations require most railway operators to maintain an SMS, and hold a safety certificate or authorisation indicating that the SMS has been accepted by the Office of Rail and Road.
-
Content Article
Skybrary: Safety Management System in aviation
Patient Safety Learning posted an article in Organisational
The objective of a Safety Management System is to provide a structured management approach to control safety risks in operations. Effective safety management must take into account the organisation’s specific structures and processes related to safety of operations. -
Content ArticleThe Resilient Health Care Society (RHCS) is a non-profit organisation registered in Sweden. The goal of the Society is to provide an international forum for coordination and exchange of principles, practices, and experiences, by bringing together researchers and professionals working with or interested in Resilient Health Care. Research and practice in Resilient Health Care aims to develop and promote practical solutions, based on a solid scientific foundation, to ensure that health care systems can perform as intended under expected and unexpected conditions alike. Links to some of their publications can be found below.
-
Content ArticleHistorical and current methodologies in patient safety are based on a deficit-based model, defining safety as the absence of harm. This model is aligned with the human innate negativity bias and the general philosophy of health care: to diagnose and cure illness and to relieve suffering. While this approach has underpinned measurable progress in healthcare outcomes, a common narrative in the healthcare literature indicates that this progress is stalling or slowing. It is important to learn from and improve poor outcomes, but the deficit-based approach has some theoretical limitations.
-
Content ArticleThese slides provide the outline of a tutorial about the Causal Analysis using System Theory (CAST) and System-Theoretic Accident Model and Processes (STAMP) approaches to accident analysis, delivered at the Second STAMP Conference in 2013. The presentation slides cover: Model and method: Why STAMP and CAST? Why do accident analysis? Goals for an accident analysis technique Overcoming hindsight bias CAST worked example of emergency plane landing
-
Content ArticleThis article by Penelope Hawe from the Menzies Center for Health Policy at the University of Sydney, looks at complexity and how it increases the unpredictability of interventions in systems. She argues that new metaphors and terminology are needed to capture the recognition that knowledge generation comes from the hands of practitioners as much as it comes from intervention researchers.
-
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. Jordan talks to us about his journey from drama school to patient safety, how the new Patient Safety Incident Response Framework (PSIRF) will change the way the NHS looks at safety, and how his love of driving makes him think differently about his role. A transcript of the interview is also available below.- Posted
- 1 comment
-
1
-
- (and 6 more)
-
Content ArticleThe fishbone diagram is a widely-used patient safety tool that helps to facilitate root cause analysis discussions. The authors of this article in the journal Diagnosis expanded this tool to reflect how both systems errors and individual cognitive errors contribute to diagnostic errors. They describe how two medical centres in the US have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets their patient safety and educational needs.
-
Content Article
Laurence Goldberg, an independent pharmaceutical consultant, discusses the effectiveness and also the potential for harm of unit-dose medicines distribution. -
Content ArticleThe pandemic has emphasised the high risk of avoidable harm to patients, health workers, and the general public, and has identified a range of safety gaps across all core components of health systems at all levels. The World Health Organization (WHO)'s rapid review ‘Implications of the COVID-19 pandemic for patient safety’ explores impacts that the COVID-19 pandemic did have on patient safety in terms of risks and avoidable harm, specifically in terms of diagnostic, treatment and care management related issues as well as highlights the main patterns of these implications within the broader health system context.
-
Content ArticleProfessor Peter Brennan is a NHS Consultant Surgeon in Portsmouth, specialising in head and neck cancer. In this episode of the Human Factor Podcast, Peter discusses how he is driving Human Factors approaches from his perspective. To date, Peter has published over 700 publications including more than 80 on Human Factors and patient safety. His HF work has changed the delivery of postgraduate surgery exam delivery in the UK and abroad. Watch all the Human Factors Podcast episodes here.
-
Content ArticleProfessor Ron McLeod's presentation on the Chartered Institute of Ergonomics & Human Factors (CIEHF) White Paper on Human Factors in highly automated systems.
-
Content ArticleEach year, 7,000 to 9,000 people die as a result of a medication errors in the US, and the total cost of looking after patients with medication-associated errors exceeds $40 billion. Alongside this financial cost, adverse events caused by medication errors also cause patients significant psychological and physical pain and suffering. The article aims to: identify the most common medication errors. review some of the critical points at which medication errors are most likely to occur. outline strategies to prevent medication errors occurring. summarise multidisciplinary team strategies for decreasing medication errors.
-
Content ArticleIn this blog, Chris Day, Director of Engagement at the Care Quality Commission (CQC) sets out more detail on the CQC’s role in the assessment of Integrated Care Systems (ICSs). He highlights the importance of developing regulation that earns the trust of both people using services and those working in them. He outlines how the CQC will use its new responsibilities under the Health and Care Act 2022 to assess the extent to which each ICS understands the needs of its local population and whether it is working effectively in collaboration, with valued input from all health and care partners.
