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Showing results for tags 'System safety'.
Found 518 results
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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 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. -
Content ArticleThe Professioan Records Standards Body are a unique collaboration of groups representing those who receive and provide health and social care across the UK, as well as those providing the IT systems that support care. Emma Robertson is the patient lead on the Professional Records Standards Body (PRSB), work to accredit apps and digital health technologies. She speaks to PRSB about why she got involved with the work and the benefits and challenges of using apps to support health and care.
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Content ArticleSeveral countries have national policies and programmes requiring hospitals to use quality and safety (QS) indicators. To present an overview of these indicators, hospital-wide QS (HWQS) dashboards are designed. There is little evidence how these dashboards are developed. This paper, published by BMJ Quality & Safety, studies the challenges faced developing these dashboards in Dutch hospitals.
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Content ArticleThis paper, published by BMJ Quality & Safety, argues that discharge handovers are often haphazard. Healthcare professionals do not consider current handover practices safe, with patients expected to transfer information without being empowered to understand and act on it. This can lead to misinformation, omission or duplication of tests or interventions and, potentially, patient harm. Vulnerable patients may be at greater risk given their limited language, cognitive and social resources. Patient safety at discharge could benefit from strategies to enhance patient education and promote empowerment.
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Content Article
Patient safety alerts
PatientSafetyLearning Team posted an article in NHS Improvement
Typically issued in response to a new or under-recognised patient safety issue with the potential to cause death or severe harm. NHS Improvement aim to issue warning alerts as soon as possible after becoming aware of an issue and identifying that healthcare providers could take constructive action to reduce the risk of harm. Warning alerts ask healthcare providers to agree and coordinate an action plan, rather than to simply distribute the alert to frontline staff. -
Content ArticleThe need for effective teamwork and improved communication amongst caregivers is increasingly recognised in healthcare policy worldwide. As healthcare organisations navigate in highly complex contexts, they are largely dependent on thorough collaboration and sharing of information between staff at all levels. Promoting high‐quality teamwork based on effective and frequent communication is therefore essential for developing well‐functioning healthcare organisations
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Content Article
Patient safety in oral surgery
PatientSafetyLearning Team posted an article in Dentist
This article from the British Association of Oral Surgeons (BAOS) highlights that these clinicians perform a high volume of multi-site complex procedures, on anxious patients who are frequently conscious, that have the potential for error to occur. -
Content Article‘Safety differently’ is about relying on people’s expertise, insights and the dignity of 'work as actually done' to improve safety and efficiency. It is about halting or pushing back on the ever-expanding bureaucratisation and compliance of work. The cost of compliance and bureaucracy can be mind-boggling, with every person working some eight weeks per year just to cover the cost of compliance, paperwork and bureaucratic accountability demands. This is non-productive time. It has also stopped progressing safety. Over the last two decades, safety improvements have flat-lined (as measured in fatalities and serious injury rates, for instance) despite a vast expansion of compliance and bureaucracy.
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Content ArticleRecently, there have been a number of advances in technology, including in mobile devices, globalization of companies, display technologies and healthcare, all of which require significant input and evaluation from human factors specialists. Accordingly, this textbook has been completely updated, with some chapters folded into other chapters and new chapters added where needed. The text continues to fill the need for a textbook that bridges the gap between the conceptual and empirical foundations of the field.
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Content Article
Human factors and ergonomics in practice (2017)
Claire Cox posted an article in Recommended books and literature
This edited book concerns the real practice of human factors and ergonomics (HF/E), conveying the perspectives and experiences of practitioners and other stakeholders in a variety of industrial sectors, organisational settings and working contexts. The book blends literature on the nature of practice with diverse and eclectic reflections from experience in a range of contexts, from healthcare to agriculture. It explores what helps and what hinders the achievement of the core goals of HF/E: improved system performance and human wellbeing. -
Content ArticleWhen faced with a ‘human error’ problem, you may be tempted to ask 'Why didn’t these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable people in it.
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Content ArticleIncreased concern for patient safety has put the issue at the top of the agenda of practitioners, hospitals, and even governments. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. Yet the discourse is often oversimplified and underdeveloped. Written from a scientific, human factors perspective, Patient Safety: A Human Factors Approach delineates a method that can enlighten and clarify this discourse as well as put us on a better path to correcting the issues.
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Content ArticleMedical errors rank as the eighth leading cause of death in the U.S. Clearly medical errors are an epidemic that needs to be contained. Despite these numbers, patient safety and medical errors remain an issue for physicians and other clinicians. This book bridges the issues related to patient safety by providing clinically relevant, vignette-based description of the areas where most problems occur. Each vignette highlights a particular issue such as communication, human factors, electronic health records, and provides tools and strategies for improving quality in these areas and creating a safer environment for patients.
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Content ArticleJo Wailling is a registered nurse and research associate with the Diana Unwin Chair in Restorative Justice, Victoria University of Wellington. Jo presented on restorative practice at the Commission’s mental health and addiction (MHA) quality improvement programme workshop held in Wellington on 26 June for mental health and addiction leaders. This blog is a continuation of that presentation.
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Content ArticleA National Patient Safety Alert has been issued around the risk of depleted batteries in intraosseous injectors. The intraosseous (IO) route (that is, through the bone marrow) is used to access the venous system when intravenous access is not possible to administer medicines or fluids, often in emergency situations, including cardiopulmonary resuscitation. IO access is most commonly achieved using a battery-powered injector. As the battery is sealed within the device and cannot be recharged or replaced, the first sign a battery may be depleted is in some circumstances when it does not work. The alert asks providers to replace any battery-powered IO devices that do not have a battery power indicator light with ones with a display that shows how much power is remaining. Where IO devices with a battery power indicator are used, providers are asked to take steps to regularly check these devices to ensure sufficient battery power remains so the devices are always ready and available.
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Content Article
MedLed: What is systems thinking?
PatientSafetyLearning Team posted an article in Organisational
In this article, Human Factors Consultant, Jayne Higgs, talks about systems thinking. She highlights the different components that contribute to systems thinking (including human factors) and argues that this approach can aid a move away from a narrow-perspective blame culture. -
Content ArticleThis report summarises the themes that emerged from a restorative process to hear from New Zealand men and women affected by surgical mesh. Restorative justice approaches and practices were used to respond to harm from surgical mesh. This innovation differs to medicolegal action and inquiry approaches in other countries. A restorative approach intended to create a safe space to explore multiple experiences and perspectives of harm.
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Content Article
Each baby counts: Aims and objectives
Claire Cox posted an article in Maternity
In the UK, each year over 1000 babies die or are left with severe brain injury, not because they are born too soon or too small, or have a congenital abnormality, but because something goes wrong during labour. The Royal College of Obstetricians and Gynaecologists does not accept that all of these are unavoidable tragedies, and with the Each baby counts project, they are aiming to reduce this unnecessary suffering and loss of life by 50% by 2020. -
Content ArticleThis article, published by Forbes, looks at the airline industry and discusses the value in not only studying what pilots do wrong, but also what they do right. This can be translated into healthcare, we know lots about what has gone wrong in healthcare but not so much about the small, quiet things that go right. 'In aviation safety, it’s like we’ve been trying to learn about marriage by only studying divorce.' Written by Kirsty Kiernan a professor at Embry-Riddle Aeronautical University who teaches and conducts research in unmanned systems and aviation safety.
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Content ArticleLast year, 63 healthcare professionals in England were found stealing controlled drugs and/or providing care whilst working under the influence of controlled drugs. By law, designated bodies must have a Controlled Drug Accountable Officer (CDAO). This is a case study demonstrating the role of the CDAO and safety of controlled drugs.
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Safety myths, a blog by Suzette Woodward
Claire Cox posted an article in By researchers and academics
This is the first in a series of blog posts by Suzette Woodward around implementing patient safety. Part one describes the growing sense of unease about the way we do safety in healthcare and how we can do it differently. It describes the dominant approach to patient safety in healthcare we use today – which has been coined by some as Safety I. -
Content ArticleOne important strategy for system-wide safety improvement involves investigating and addressing the system-wide sources of risk that contribute to unsafe care. Carl MaCrae in his paper published in the Journal of the Royal Society of Medicine highlights five strategies to ensure patient safety investigations actually improve patient safety.
