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Showing results for tags 'System safety'.
Found 518 results
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Content ArticleTo celebrate the second annual World Patient Safety Day, the Canadian Patient Safety Institute (CPSI) are proud to premiere the documentary, Building a Safer System, showcasing the 17-year impact of the Canadian Patient Safety Institute. The film is followed by an expert panel discussion of the theme, Health Worker Safety – A Priority for Patient Safety.
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Content ArticleThis handbook provides tools for designing a structure for a management system, as well as the tools for documenting processes within it. The starting point is based on current safety research. The book is designed for medical professionals, managers, project members, politicians, public officials, and executives-all who work with patient safety matters. The content shows a new way to healthcare management, presenting an alternative approach together with concrete advice on how healthcare executives and practitioners can begin to think and act differently in order to provide safe healthcare.
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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has struggled to embrace system safety approaches, misapplied or misinterpreted others, and has stuck to a range of outdated and potentially counter-productive myths even has safety science has developed.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 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 Article
Ehi Iden, hub topic lead for Occupational Health and Safety: OSHAfrica, reflects on a patient safety incident early on in his career. -
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 ArticleA report from MedStar Health National Center for Human Factors in Healthcare on the work and research they do in human factors.
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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.
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Content ArticleThis programme referred to as CUSP is an intervention methodology that will help you to learn from mistakes and improve your team's (and organisation's) safety culture. Watch this Johns Hopkins Medicine's video on CUSP.
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Content ArticleLearn how the key principles of safe design – standardize care, create independent checklists for important processes, and learn from defects – can be applied to create safer systems that benefit patients, health care teams, and hospitals.
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Content ArticlePresentation from Paul Bowie, Programme Director, NHS Education for Scotland on human factors and ergonomics.
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Content ArticleAnnie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without a blame and shame approach.
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Nigeria: World Patient Safety Day 2020
Patient Safety Learning posted an article in Staff safety
Nigeria joined the rest of the world to celebrate World Patient Safety Day on 17 September 2020. This event was jointly organised this year in Nigeria by the Occupational Health and Safety Managers (OHSM), Medical and Health Workers Union of Nigeria (MHWUN), OSHAfrica, International Trade Union Congress (ITUC-Africa), Nigeria Labour Congress (NLC), Patient Safety Movement Foundation (PSMF) and the World Health Organization (WHO). -
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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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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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 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 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 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 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 ArticleIn this talk, Steven Shorrock outlines seven fallacies of work-as-imagined, concerning outcomes happen, how people work, how we design and implement, and how we think. A number of examples provided by healthcare workers are given. The talk was given at the HSJ Patient Safety Congress 2019.
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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.
