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Showing results for tags 'System safety'.
Found 520 results
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Content ArticleNeil Spenceley is a paediatric intensivist and is the National Lead for Paediatric Patient Safety. This talk is packed with nuggets that will change the way you view the world in which you practice. Neil explains Safety 1 and Safety 2 thinking. The talk is wide-ranging and covers poor behaviours in healthcare both at a personal level and at an institutional level. This talk was recorded live at Don't Forget the Bubbles 2019 in London, England.
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Content ArticleHuman factors is a critical component of future aviation success in both military and civil aviation systems, especially where it concerns safety. This white paper from the Chartered Institute of Ergonomics and Human Factors contains the visions of 15 ‘thought leaders’, showing how they believe aviation evolution will unfold between now and 2050, and the critical role of human factors in ensuring system performance and safety. The thoughts in this paper can be applied to human factors in health and social care.
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News ArticleFollowing four deaths and more than 300 incidents with steroid replacement therapy involving patients with adrenal insufficiency in the past two years, patients at risk of adrenal crisis will be issued with a steroid emergency card. All adults with primary adrenal insufficiency (AI) will be issued an NHS steroid emergency card to support early recognition and treatment of adrenal crisis, a National Patient Safety Alert has said. The cards will be issued by prescribers — including community pharmacists — from 18 August 2020. AI is an endocrine disorder, such as Addison’s disease, which can lead to adrenal crisis and death if not identified and treated. Omission of steroids in patients with AI, particularly during physiological stress such as an additional illness or surgery, can also lead to an adrenal crisis. The alert has requested that “all organisations that initiate steroid prescriptions should review their processes/policies and their digital systems/software and prompts to ensure that prescribers issue a steroid emergency card to all eligible patients” by 13 May 2021. Read full story Source: The Pharmaceutical Journal, 17 August 2020
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Content ArticleProgress enables the creation of more automated and intelligent machines with increasing abilities that open up new roles between humans and machines. Only with a proper design for the resulting cooperative human–machine systems, these advances will make our lives easier, safer and enjoyable rather than harder and miserable. Starting from examples of natural cooperative systems, the paper from Flemisch et al. investigates four cornerstone concepts for the design of such systems: ability, authority, control and responsibility, as well as their relationship to each other and to concepts like levels of automation and autonomy.
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Content ArticleConcerns for patient safety persist in clinical oncology. Within several nonmedical areas (eg, aviation, nuclear power), concepts from Normal Accident Theory (NAT), a framework for analysing failure potential within and between systems, have been successfully applied to better understand system performance and improve system safety. Clinical oncology practice is interprofessional and interdisciplinary, and the therapies often have narrow therapeutic windows. Thus, many of the processes are, in NAT terms, interactively complex and tightly coupled within and across systems and are therefore prone to unexpected behaviours that can result in substantial patient harm. To improve safety at the University of North Carolina, Chera et al. have applied the concepts of NAT to their practice to better understand their systems’ behaviour and adopted strategies to reduce complexity and coupling. Furthermore, recognising that you cannot eliminate all risks, they have stressed safety mindfulness among their staff to further promote safety. Many specific examples are provided herein. The lessons from NAT are translatable to clinical oncology and may help to promote safety.
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Content ArticleDementia is a cause of disability and dependency associated with high demands for health services and expected to have a significant impact on resources. Care policies worldwide increasingly rely on family caregivers to contribute to service delivery for older people, and the general direction of health care policy internationally is to provide care in the community, meaning most people will receive services there. Patient safety in primary care is therefore important for future care, but not yet investigated sufficiently when services are carried out in patients’ homes. In particular, we know little about how family carers experience patient safety of older people with dementia in the community.
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Content Article
Acute Data Alignment Programme (ADAPt)
Claire Cox posted an article in Data and insight
The Acute Data Alignment Programme (ADAPt) is a joint programme between NHS Digital and the Private Healthcare Information Network (PHIN) which is looking to adopt common standards for data collections and performance measures across both the NHS and private healthcare. This will ensure that relevant information is consistently recorded and available so it can be more easily analysed and compared. -
Content ArticleAuthors of this article, published by Health Europa, argue that proactive patient safety and risk prevention are key to helping healthcare organisations surveil and mitigate global and local risks.
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Content ArticleThis article from Susan Carr discusses how fear is keeping patients from getting the care they need. The author highlights the importance of recognising that rebuilding trust in the system disrupted by COVID-19 will take time and the role of leaders to anchor this effort.
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Content ArticleThis study from Sanko et al., published in Simulation in Healthcare, found that improvements in systems thinking increase adverse event (AE) reporting patterns among undergraduate nursing students participating in a simulation exercise. The authors suggest that prelicensure training include reinforcement of systems thinking principles to achieve patient safety improvements.
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Content ArticlePlan Do Study Act (PDSA) cycles are an ideal quality improvement tool that can be used to test an idea by temporarily trialling a change and assessing its impact.
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Content Article‘Systems thinking’ is often recommended in healthcare to support quality and safety activities but a shared understanding of this concept and purposeful guidance on its application are limited. Healthcare systems have been described as complex where human adaptation to localised circumstances is often necessary to achieve success. Principles for managing and improving system safety developed by the European Organisation for the Safety of Air Navigation (EUROCONTROL; a European intergovernmental air navigation organisation) incorporate a ‘Safety-II systems approach’ to promote understanding of how safety may be achieved in complex work systems. Authors of this paper, published by BMJ Open Quality, aimed to adapt and contextualise the core principles of this systems approach and demonstrate the application in a healthcare setting.
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Content ArticleThis article from Wood and Wiegmann, in the International Journal for Quality in Healthcare, discusses the action hierarchy, which is a tool for generating corrective actions to improve safety and focuses on those recommendations relying less on human factors and more on systems change. The authors propose a multifaceted definition of ‘systems change’ and a rubric for determining the extent to which a corrective action addresses ‘systems change’ (‘systems change hierarchy’).
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Content Article
Systems Approach Resources (NES)
PatientSafetyLearning Team posted an article in Improving systems of care
Complex systems consist of many dynamic interactions between people, tasks, technology, environments (physical and social), organisational structures and arrangement and external factors, such as the influence of national policy or regulation. The nature of these interactions often results in unpredictable changes in system conditions (such as patient demand, staff capacity, available resources and organisational constraints) and goal conflicts (such as the frequent pressure to be efficient and thorough). To achieve success, people frequently adapt to these system conditions and goal conflicts. But rather than being planned in advance, these adaptations are often approximate responses to the situations faced at the time. Therefore, to understand patient safety or staff wellbeing (and other emergent outcomes) we need to look beyond the individual components of care systems to consider how outcomes (wanted and unwanted) emerge from interactions in, and adaptations to, everyday working conditions. Follow the link below to the NHS Education Scotland (NES) website to find out more about systems thinking and access systems approach resources. -
Content Article
NES: Safety culture discussion cards
PatientSafetyLearning Team posted an article in Good practice
Safety culture can be described as our: 1. Values (what is important) 2. Behaviours (the way we do things around here) 3. Beliefs (how things work). Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. NHS Education for Scotland (NES) has adapted these safety culture discussion cards (designed by EUROCONTROL) to help us to do this. Follow the link below to download the cards.- Posted
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Content ArticleHuman Factors (Ergonomics) is the study of human activity (inside and outside of work). Its purpose as a scientific discipline is to enhance wellbeing and performance of individuals and organisations. A number of different definitions of Human Factors exist. The key principles are the interactions between you and your environment both inside and outside of work and the tools and technologies you use. This webpage from NHS Education Scotland (NES) provides links to a number of useful Human Factors resources used in healthcare. Topics include: Training Culture Leadership Systems Thinking Communication.
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Content Article
Diagnostic Errors: Technical Series on Safer Primary Care (2016)
Patient-Safety-Learning posted an article in WHO
This document from the World Health Organization raises awareness about strategies that could reduce diagnostic errors in primary care. It highlights the importance of examining diagnostic errors, identifies the most common types of diagnostic error in primary care and describes potential solutions. -
Content ArticleThe Chartered Institute of Ergonomics & Human Factors has issued today their White Paper on Adverse Events. This report states what good practice should be in incident investigation across all industries, including health and social care. The White Paper is designed to: 1. Help organisations understand a human factors perspective to investigating and learning from adverse events. 2. Provide key principles organisations can apply to capture the human contribution to adverse events. How organisations learn, and fail to learn, from adverse events is discussed.
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Content ArticleReasonable adjustments to the care of people with learning disabilities who receive hospital care are beneficial for all involved. This article, published in the Nursing Times, uses two case studies to demonstrate their benefits. Author, Linda Phillips, is a learning disability health liaison nurse at Hywel Dda University Health Board.
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Content ArticleProviding patients with access to electronic health records (EHRs) may improve quality of care by providing patients with their personal health information and involving them as key stakeholders in the self-management of their health and disease. With the widespread use of these digital solutions, there is a growing need to evaluate their impact, in order to better understand their risks and benefits and to inform health policies that are both patient-centred and evidence-based. The objective of this paper, published by BMJ Quality & Safety, was to evaluate the impact of sharing electronic health records (EHRs) with patients and map it across six domains of quality of care: patient-centredness effectiveness efficiency timeliness equity safety.
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Content ArticleLt Col Chris Gibson, MBE, Specialist Leadership Adviser, Former Lieutenant Colonel, Defence Medical Directorate, gives the keynote address at the Kings Fund event in June 2018, Innovation in health and care: overcoming the barriers to adoption and spread.
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Content Article
This is the US Military Health System
Claire Cox posted an article in Stories from the front line
Army, Navy and Air Force medical personnel care for Soldiers, Sailors, Airmen, Marines, Coast Guardsmen and all who come in harm's way – on and off the battlefield. This video, in less than 4.5 minutes, provides a glimpse of the unique mission and benefits of military medicine. -
News Article
After coronavirus, we may not recognise changed NHS
Patient Safety Learning posted a news article in News
In many ways it is wrong to talk about the NHS restarting non-coronavirus care. A lot of it never stopped — births, for instance, cannot be delayed because of a pandemic. However, exactly what that care looks like is likely to be very different from what came before. There are more video and telephone consultations and staff treat patients from behind masks and visors. That is likely to be the case for some time, experts have told The Times. Read full story (paywalled) Source: The Times, 6 June 2020 -
Content ArticleThis month’s Letter from America looks at perspectives examining collective responses to the COVID-19 pandemic through a systems analysis lens. Letter from America is the latest in a Patient Safety Learning blog series highlighting new accomplishments in patient safety from the United States.
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Content ArticleAs the death toll from COVID-19 rapidly increases, the need to make a timely and accurate diagnosis has never been greater. Even before the pandemic, diagnostic errors (i.e., missed, delayed, and incorrect diagnoses) had been one of the leading contributors to harm in health care. The COVID-19 pandemic is likely to increase the risk of such errors. Based on emerging literature and collaborative discussions across the globe, Gandhi and Singh propose a new typology of diagnostic errors of concern in the COVID-19 era. These errors span the entire continuum of care and have both systems-based and cognitive origins. While some errors arise from previously described clinical reasoning fallacies, others are unique to the pandemic. We provide a user-friendly nomenclature while describing eight types of diagnostic errors and highlight mitigation strategies to reduce potential preventable harm caused by those errors.
