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Showing results for tags 'System safety'.
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Content ArticleHealth Education England (HEE) has published the first NHS-wide Patient Safety Syllabus which applies to all NHS employees and will result in all NHS employees receiving enhanced patient safety training. Written by the Academy of Medical Royal Colleges and commissioned by HEE the new National Patient Safety Syllabus outlines a new approach to patient safety emphasising a proactive approach to identifying risks to safe care while also including systems thinking and human factors. Level one and two learning materials will be available on the E Learning for Health platform for staff to access and complete from August and September 2021.
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Content Article
Why investigate? Part 11: We have a situation
Graham Edgar posted an article in Why investigate? Blog series
In the latest blog in the 'Why investigate' blog series, Professor Graham Edgar discusses situational awareness. -
Content ArticleAs a team, this worksheet can be used as a prompt to highlight the various system-wide factors that contribute to the issue at hand (e.g. implementing a new way of working; managing change or learning from a safety incident); seek to understand how these factors relate and interact to produce outcomes (desirable or undesirable).
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Content ArticleThis paper from Samson et al. discusses the properties of complex systems and a systems approach to incident investigation, describes the differences between reactive and proactive safety approaches and describes some of the system-focused models applied to patient safety incident investigations.
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Content ArticleThe Serenity Integrated Mentoring (SIM) model is described as "an innovative mental health workforce transformation model that brings together the police and community mental health services, in order to better support 'high intensity users' of Section 136 of the Mental Health Act (MHA) and public services." The SIM model is part of a 'High Intensity Network' (HIN) approach, which is now live in all south London boroughs. In this hub post, Steve Turner highlights the benefits and risks of this approach and seek your views on it.
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Content ArticleThe COVID-19 pandemic has profoundly impacted the country’s health systems and diminished its capability to provide safe and effective healthcare. This article from Sharda Narwal and Susmit Jain attempts to review patients safety issues during COVID-19 pandemic in India, and derive lessons from national and international experiences to inform policy actions for building a ‘resilient health system’
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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 ArticleDr Abdulelah Alhawsawi, is the ex-founding Director General of the Saudi Patient Safety Center, and Ministry of Health Advisor on Patient Safety. In this video, he interviews Rt Hon Jeremy Hunt, Chair of the Health and Social Care Select Committee and former Health Secretary. They discuss safety in healthcare, avoidable deaths and how we can realise the vision of zero harm.
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Content ArticleHave you ever come across a ‘problematic solution’ that was implemented in your workplace, and wondered, “How did this come to be?” Wherever you sit in an organisation, the chances are that you have. Many problematic solutions emerge from a top-down process that Steven Shorrock in this blog will call work-as-imagined solutioneering. In this post, he outlines a typical process of 10 steps by which problematic solutions come into being. Some of the steps may be skipped, but with the same outcome: a problematic solution. At the end of the post, you will find 10 ‘solutions’ from healthcare, provided by healthcare practitioners.
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Content ArticleThis chapter from the book 'Learning from High Reliability Organisations' focuses on a systems-based technique for accident analysis referred to as the AcciMap approach. The technique involves the construction of a multi-layered diagram, in which the various causes of an accident are arranged according to their causal remoteness from the outcome. It is particularly useful for establishing how factors in all parts of a sociotechnical system contributed to an organisational accident and for arranging the causes into a coherent diagram that reveals how they interacted to produce that outcome. By identifying these causal factors and the interrelationships between them in this way, it is possible to identify problem areas that should be addressed to improve the safety of the system and prevent similar occurrences in the future.
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Content ArticleThroughout Jens Rasmussen’s career there has been a continued emphasis on the development of methods, techniques and tools for accident analysis and investigation. In this paper, Waterson et al. focus on the evolution and development of one specific example, namely Accimaps and their use for accident analysis.
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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 -
Content ArticleThe Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models provide a framework for integrating Human Factors and Ergonomics (HFE) in health care quality and patient safety improvement. As care becomes increasingly distributed over space and time, the “process” component of the SEIPS model needs to evolve and represent this additional complexity. In this paper, Carayon et al. review different ways that the process component of the SEIPS models have been described and applied. Carayon et al. propose the SEIPS 3.0 model, which expands the process component, using the concept of the patient journey to describe the spatio-temporal distribution of patients’ interactions with multiple care settings over time. This new SEIPS 3.0 sociotechnical systems approach to the patient journey and patient safety poses several conceptual and methodological challenges to HFE researchers and professionals, including the need to consider multiple perspectives, issues with genuine participation, and HFE work at the boundaries.
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Content ArticleThis BMJ editorial is written by Marian Knight, professor of maternal and child population health and Charlotte Bevan, a bereaved parent. They argue that systems and thinking need to change, and that our healthcare structures are biased against complexity and are not set up to deliver seamless multidisciplinary care.
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Content ArticlePresentation from Terry Wilcutt Chief, Safety and Mission Assurance, and Hal Bell Deputy Chief, Safety and Mission Assurance at NASA.
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Content Article
Ehi Iden, hub topic lead for Occupational Health and Safety: OSHAfrica, reflects on a patient safety incident early on in his career. -
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 -
Content ArticleThe COVID-19 pandemic has exacerbated preexisting weaknesses in the global supply chain. Regional assessments by the Food and Drug Administration (FDA), European Medicines Agency (EMA), and independent consultants, have demonstrated various contributory causal factors requiring changes in policy, relationships, and incentives within the dynamic and developing networks. Human factors and ergonomics (HFE) is an approach that encourages sociotechnical systems thinking to optimize the performance of systems that involve human activity. The global supply chain can be considered such a system. However, it has neither been systematically examined from this perspective.
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Content ArticleDespite the application of a huge range of human factors (HF) principles in a growing range of care contexts, there is much more that could be done to realise this expertise for patient benefit, staff well-being and organisational performance. Healthcare has struggled to embrace system safety approaches, misapplied or misinterpreted others, and has stuck to a range of outdated and potentially counter-productive myths even has safety science has developed. One consequence of these persistent misunderstandings is that few opportunities exist in clinical settings for qualified HF professionals. Instead, HF has been applied by clinicians and others, to highly variable degrees—sometimes great success, but frequently in limited and sometimes counter-productive ways. Meanwhile, HF professionals have struggled to make a meaningful impact on frontline care and have had little career structure or support. However, in the last few years, embedded clinical HF practitioners have begun to have considerable success that are now being supported and amplified by professional networks. The recent COVID-19 experiences confirm this. Closer collaboration between healthcare and HF professionals will result in significant and ultimately beneficial changes to both professions and clinical care.
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Content ArticleThis article from the book 'Patient Safety and Quality: An Evidence-Based Handbook for Nurses' looks at the impact of the architectural design of a hospital facility on patient safety. This includes considering the design of hospital technology and equipment. The authors highlight the ways in which physical design can make healthcare systems and processes safer for patients and staff. They also identify indirect benefits of system design that may contribute to this, including improved staff wellbeing and making patients feel safer while in care environments.
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Content ArticleThis editorial in BMJ Quality & Safety suggests that individual doctors' conduct, performance and responsibility are important factors in improving patient safety. The authors argue that although a 'systems approach' is important, it is necessary to examine the role of individuals within those systems. They highlight recent research that points to small numbers of individual doctors who contribute repeatedly to patient dissatisfaction and harm, and to difficult working environments for other staff. They suggest that identifying and intervening with these individuals plays a role in the wider systems approach to patient safety. They also highlight an urgent need for further research into identifying and responding to problematic clinicians.
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Content ArticleSafety governance refers to the approaches taken to minimise the risk for patient harm across an entity or system. It typically comprises steering and rule-making functions such as policies, regulations and standards. To date, governance has focused on the clinical level and the hospital setting, with limited oversight and control over safety in other parts of the health system. All 25 countries that responded to a 2019 OECD Survey of Patient Safety Governance have enacted legislation that aims to promote patient safety. These practices include external accreditation and inspections of safety processes and outcomes. Safety governance models are also moving away from punishment and shaming towards increased trust and openness. Learning from success as well as failures represents a paradigm shift in safety governance, an approach that has been increasingly adopted in OECD countries.
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Content ArticleSafety systems are socio-cultural in nature, characterised by people, their relationships to one another and to the whole. This study, publishe in the International Journal for Quality in Health Care, aimed to (i) map the social networks of New Zealand’s quality improvement and safety leaders, (ii) illuminate influential characteristics and behaviours of key network players and (iii) make recommendations regarding how networks might be optimised.
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Content ArticleIn this 30 minute video presentation, we hear from Dr Victoria Brazil, Professor of Emergency Medicine and Director of Simulation, Gold Coast Health Service. Dr Brazil talks through the benefits and complexities of simulation training using real life footage to illustrate key points. She suggests there are three ways healthcare can be improved using simulation: Simulation to explore Simulation to test Simulation to embed.
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Content ArticleIn this analysis, published by the BMJ, professor of public health, Sarah Salway and colleagues, argue that the UK health system must take urgent action to better understand and meet the health needs of migrants and ethnic minority people.
