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Showing results for tags 'System safety'.
Found 515 results
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Content Article
NHS Patient Safety Syllabus v. 2.1 (June 2022)
Patient Safety Learning posted an article in Training & education
The Academy of Medical Royal Colleges and the University of Warwick have developed this NHS Patient Safety syllabus to complement it as the basis for education and training for staff throughout the NHS. -
Content Article
Rethinking healthcare as a safety-critical industry
Patient Safety Learning posted an article in Barriers
The discipline of ergonomics, or human factors engineering, has made substantial contributions to both the development of a science of safety, and to the improvement of safety in a wide variety of hazardous industries, including nuclear power, aviation, shipping, energy extraction and refining, military operations, and finance. It is notable that healthcare, which in most advanced societies is a substantial sector of the economy and has been associated with large volumes of potentially preventable morbidity and mortality, has not up to now been viewed as a safety critical industry. This paper from Robert L Wears proposes that improving safety performance in healthcare must involve a re-envisioning of healthcare itself as a safety-critical industry, but one with considerable differences from most engineered safety-critical systems. This has implications both for healthcare, and for conceptions of safety-critical industries. -
Content ArticleThis article in USA Today looks at how the Covid-19 pandemic has caused setbacks in hospitals' patient safety progress. It looks at data from a report by the US non-profit health care watchdog organisation, Leapfrog, which show increases in hospital-acquired infections, including urinary tract and drug-resistant staph infections, as well as infections in central lines. These infections spiked during the pandemic and remain at a five-year high. The article also looks at the case study of St Bernard Hospital in Chicago, which was rated poorly by Leapfrog on handwashing, medication safety, falls prevention and infection prevention, but then made huge progress in improving safety. It describes the different approaches and interventions taken by St Bernard.
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Content Article
Breaks from operational duty are an important factor in the management of fatigue. But as highly committed and professional operational staff often perform several secondary tasks and activities—inside or outside the ops room—breaks can become a victim. This blog by Chartered Ergonomist and Human Factors Specialist Stephen Shorrock offers some general guidelines about what kinds of tasks add to stress and fatigue and should be avoided during rest breaks. He places break activities into three categories which place different demands on the individual: red, amber and green activities. He also highlights that when it comes to breaks from operational duty, changes in activity are the key to reducing fatigue-related risks. -
News Article
NHSE tells trusts to ‘immediately stop all ambulance handover delays’
Clive Flashman posted a news article in News
· Trusts told to identify actions to “immediately stop all delays” · Letter calls for issue to be discussed at every board meeting · It follows concern over harm to patients from delays Trusts and integrated care systems are being told by NHS England and Improvement to take urgent action to ”immediately stop all delays” to ambulance handovers, which will require “difficult choices”. A letter yesterday from NHS England’s medical director, director for emergency and elective care, and its regional directors was sent to all local chief executives and chairs yesterday. It also says they should discuss the issue of ambulance handovers at every board meeting they hold, warns that “corridor care” is “unacceptable as a solution”, and says ambulances should not be used as “additional ED cubicles”. The move comes amid signs of large numbers of very long handover delays, and concern about the risk to patients from this and the knock-on damage to ambulance response times. Read the full article here (paywalled) Original source: Health Service Journal -
News ArticleThe Health Information and Quality Authority (HIQA) has today published an overview report on the lessons learned from notifications of significant incident events in Ireland arising from accidental or unintended medical exposures in 2019. In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year.The most common errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nationally and international data, highlights an area for improvement.John Tuffy, Regional Manager for Ionising Radiation, said “The overall findings of our report indicate that the use of radiation in medicine in Ireland is generally quite safe for patients. The incidents which were reported to HIQA during 2019 involved relatively low radiation doses which posed limited risk to service users. However, there have been radiation incidents reported internationally which resulted in severe detrimental effects to patients so ongoing vigilance and attention is required." John Tuffy, continued “As the regulator of medical exposures, HIQA has a key role in the receipt and evaluation of notifications received. While a significant event is unwanted, reporting is a key demonstrator of a positive patient safety culture. A lack of reporting does not necessarily demonstrate an absence of risk. Reporting is important, not only to ensure an undertaking is compliant but because it improves general patient safety in a service and can minimise the probability of future preventative events occurring.” Read full story Source: HIQA, 9 September 2020
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News Article
NHS blame culture sees nurses referred to regulator without investigations
Patient Safety Learning posted a news article in News
Hospitals and care homes are failing to properly investigate incidents before referring nurses to their regulator, fuelling a blame culture and repeat failures, the head of the nursing watchdog has told The Independent. In her first national interview, Andrea Sutcliffe, head of the Nursing and Midwifery Council (NMC) said some employers were referring nurses without any investigation at all, while half of initial enquiries to the NMC were rejected or required further work. She told The Independent this emphasis on blaming the individual meant underlying causes of safety errors were being missed and so they were likely to be repeated. Her ambition is to transform the nursing regulator, which oversees 725,000 nurses and midwives across the UK, into a more forceful watchdog that will flag systemic issues of concern with NHS trusts and care homes. In a wide-ranging interview, Ms Sutcliffe called on ministers to ensure that planned legislation to reform the way clinicians are regulated be made transparent and maintain the public’s confidence. She also stressed that the impact of coronavirus on nurses mental health meant rushing to restart routine operations in the NHS had to be carefully planned to avoid driving nurses out of the health service. Read full story Source: The Independent, 16 March 2021 -
News Article
Lessons learned after diabetic bled to death at Shropshire hospital
Patient Safety Learning posted a news article in News
The family of a man who bled to death during kidney dialysis treatment at Royal Shrewsbury Hospital have said they believe lessons have been learned. Mohammed Ismael Zaman, known as Bolly, died after hospital staff failed to check the connection on his dialysis machine, despite it sounding an alarm after the catheter had become disconnected. During Mr Zaman’s treatment at the Royal Shrewsbury Hospital on October 18, 2019, his dialysis machine set off a venous pressure alarm. An unidentified member of staff reset the alarm without checking that the connection was still secure. As a result of the reset, Mr Zaman bled out for seven minutes losing 49% of his blood circulating volume. He was found unconscious in a pool of blood and despite resuscitation attempts, died two hours later. The coroner, Mr John Ellery concluded that the death was due to systems failure and individual neglect on the part of the unidentified staff member. Read full story Source: Shropshire Star, 16 January 2021 -
Event
Sharing accountability for patient safety
Patient Safety Learning posted an event in Community Calendar
Dr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by Thankam Gomez, Founder & CEO, Cygnia Healthcare, Mark Graban, Author of "Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement”, Management Consultant, Coach, Professional Speaker, Podcaster, Senior Advisor to KaiNexus, and Beth Beswick, Retired Vice President, Human Resources, Carteret Healthcare to discuss the background of accountability in healthcare, the history of healthcare culture, and the current organisational barriers to implementing an environment of shared learning. Additionally, panelists will discuss stepwise recommendations for the implementation of a Just Culture and will propose strategies for evaluating the impact of the shift from a blaming culture to a systems analysis approach. Register -
Content ArticleAn increasing number of healthcare artificial intelligence (AI) applications are in development or already in use, but the safety impact of using AI in healthcare is largely unknown. This qualitative study in the journal Safety Science aimed to explore how different stakeholders (patients, hospital staff, technology developers and regulators) think about safety and the safety assurance of healthcare AI. Through a series of interviews, the authors assessed stakeholder perceptions of an AI-based infusion pump in the intensive care unit. Participants expressed perceptions about: the potential impact of healthcare AI requirements for human-AI interaction safety assurance practices and regulatory frameworks for AI and the gaps that exist how incidents involving AI should be managed. The authors concluded that there is currently a technology-centric focus on AI safety, and a wider systems approach is needed. They also identified a need for greater awareness of existing standards and best practice among technology developers.
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Content ArticleThe 2022 conference returned to Parliament on Thursday 19 May and was hosted by Taiwo Owatemi MP. Entitled “The Road to Resilience”, it explored the steps that will need to be taken in the years to come to continue the momentum seen during the pandemic around the key role of HealthTech and make the healthcare system more resilient for its staff and patients. Featuring keynote speakers Sam Roberts, CEO at NICE & Lord Kamall, Minister for Technology, Innovation and Life Sciences, the conference brought together key health sector stakeholders, providing insights into the direction of UK health care, its recovery following the pandemic & how technology can play a vital role in enhancing the health system moving forward. View the recording of the conference below.
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Content ArticleRecent years have seen a surge in interest in the study of resilience in medical professionals. Concern has been expressed about the psychological wellbeing of doctors in general and of surgeons specifically, with increasing individual doctors’ resilience being suggested as a possible solution.1 However, there are potential risks as well as benefits to this focus on individual resilience. This article from Bolderston et al. explores both sides of the resilience coin, and considers potentially helpful ways of addressing psychological wellbeing and resilience in surgeons, including the development of an Acceptance and Commitment Therapy-based intervention.
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Content ArticleThis webinar by the Institute for Safe Medication Practices is aimed at healthcare providers and patient safety specialists. The conversation covers lessons learned in the aftermath of a fatal medication error and looks at common, yet often unresolved, system vulnerabilities. It also examines key strategies and priorities needed to advance an organisation's safety journey.
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Content ArticleThis Chartered Institute of Ergonomics and Human Factors (CIEHF) webinar explores near misses in three different sectors and how controls can, or cannot, be developed to prevent future events.
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Content ArticleStep Change in Safety is a member-led organisation which is working to make the UKCS the safest oil and gas province in the world in which to work. The safety of the workforce always comes first. Through collaboration, sharing knowledge and adopting best practices, workforce safety in the UKCS can be continually improved and Step Change in Safety are at the forefront in delivering that. Take a look at Step Change in Safety's resources and see how they could apply to healthcare.
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Content ArticleThe delivery of safe and effective healthcare to paediatric and neonatal patients presents unique challenges to the medication-use system. The diversity of patients within this population and the consequences of ontogeny on pharmacokinetics and pharmacodynamics directly impact the safe use of medications in children and increase the risk of adverse drug events. This review from Elkeshawi et al. will explore the medication-use system for hospitalised children and neonates, discuss vulnerabilities within this system, and provide examples of advancements made to improve the paediatric medication-use system.
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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. Mark talks to us about how he came to work in healthcare, the vital role of safety scientists and human factors specialists in improving patient safety, and the challenges involved in integrating new technologies into the health system. -
Content ArticleIn this Editorial for the journal Midwifery, maternity experts come together to respond to the Ockenden review and discuss what went wrong and what needs to happen now.
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Content ArticleIn May 2022, the National Steering Committee for Patient Safety (NSC) issued the Declaration to Advance Patient Safety to urge health care leaders across the continuum of care to recommit to advancing patient and workforce safety. The NSC called for immediate action to address safety from a total systems approach, as presented in the National Action Plan to Advance Patient Safety, and implored leaders to adopt safety as a core value and foster collective action to uphold this value.
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Content ArticleThis white paper is intended for non-specialists who may have little or no professional background in human factors and ergonomics but who are influential in the way decisions are made about the development and use of technology. The knowledge and guidance it contains is based on both fundamental scientific and applied research, as well as from deep study and learning from adverse events. The paper is based around nine principles that provide an easy-to-follow guide to human factors issues which need to be addressed when developing and implementing highly automated systems.
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Content ArticleThis document is a short introduction to systems thinking for civil servants. It is one component of a suite of documents that aims to act as a springboard into systems thinking for civil servants unfamiliar with this approach.
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Content ArticleOne box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable – does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture.
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Content ArticleAcciMap graphically maps the multiple contributing factors to an accident and their inter-relationships onto the following six levels: Government policy and budgeting. Regulatory bodies and associations. Local health economy planning and budgeting (including hospital management). Technical and operational management. Events, processes and conditions. Outcomes.
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Content ArticlePresentation on the of theme of prevention of medication error from Philip A Routledge and James Coulson (All Wales Therapeutics and Toxicology Centre). Presentation available as slides a written transcript.
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Content Article"Shaming and punishing healthcare workers when an incident occurs sets a dangerous precedent for the industry. This will lead to a culture where healthcare workers avoid reporting near misses or errors for fear of repercussions, allowing process inefficiencies and systemic problems to occur." In this letter, Michael Ramsay, CEO of the Patient Safety Movement Foundation, highlights the negative ways in which criminalising healthcare workers who make mistakes will affect patient safety. He refers to the case of RaDonda Vaught, a nurse who was convicted of criminally negligent manslaughter in March 2022 for a medication error made while working at Vanderbilt University Medical Center in Nashville.
