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Showing results for tags 'System safety'.
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Content Article17 September 2020 marks the second annual World Patient Safety Day. The theme this year is 'Health Worker Safety: A Priority for Patient Safety'. In the run up to this special event, Patient Safety Learning are publishing a series of interviews with staff from across the health and care system to highlight key issues in staff safety and gain a clearer idea of the kind of change that needs to take place to keep staff, and ultimately patients, safe. In this video, Neal Jones, Director of Patient Safety at Liverpool University Hospitals, discusses the challenges staff are currently facing and the support that they need. A transcript of the video is also included below.
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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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Content ArticleSince January 2019, the Health Information and Quality Authority (HIQA) has been the competent authority for regulating medical exposure to ionising radiation in Ireland and receives incident notifications of significant events arising from accidental or unintended medical exposures. As part of its role, HIQA is responsible for sharing lessons learned from significant events. HIQA has 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. This report provides an overview of the findings from these notifications and aims to share learnings from the investigations of these incidents.
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- Radiology
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Content ArticleMind the Gap is a Handbook to raise awareness of how symptoms and signs can present differently on darker skin as well as highlighting the different language that needs to be used in descriptors.The aim of this booklet is to educate students and essential allied health care professionals on the importance of recognising that certain clinical signs do not present the same on darker skin. This is something which is not commonly practised in medical textbooks. It is important that healthcare professionals are aware of these differences so that care of certain groups is not compromised.
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Content ArticleFifteen years after a “moral moment” transformed patient safety here, new systems and a change in culture at John Hopkins Medicine have gone a long way toward eradicating errors.
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- Harmed Care Pathway
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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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- Safety II
- Organisational learning
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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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- Medicine - Oncology
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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.- Posted
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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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- Safety report
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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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- Secondary impact
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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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- Quality improvement
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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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- Ergonomics
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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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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.- Posted
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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.- Posted
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- Primary care
- System safety
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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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- Organisational learning
- Investigation
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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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- Learning disabilities
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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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- System safety
- Safety assessment
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