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Showing results for tags 'System safety'.
Found 520 results
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Content ArticleIn April 2017, Ian Paterson, a surgeon in the West Midlands, was convicted of wounding with intent, and imprisoned. He had harmed patients in his care. The scale of his malpractice shocked the country. There was outrage too that the healthcare system had not prevented this and kept patients safe. At the time of his trial, Paterson was described as having breached his patients’ trust and abused his power. In December 2017, the Government commissioned this independent Inquiry to investigate Paterson’s malpractice and to make recommendations to improve patient safety. This report presents the Inquiry’s methodology, findings and recommendations. More importantly, it tells the story of the human cost of Paterson’s malpractice and the healthcare system’s failure to stop him, and something of the enduring impact this has had on the lives of so many people.
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Content ArticleEach quarter, the Patient Safety Movement Foundation hosts a free webinar to address a central patient safety topic. This virtual workshop session on the importance of human factors and systems safety focuses on re-designing work as opposed to re-designing the human who does the work. Incorporating a human factors and systems safety approach allows for the development and integration of knowledge, skills and attitudes that facilitate successful performance at the front lines of care. Healthcare leaders will learn how to apply human factors and systems safety concepts to understand true hazards in their organizations while fostering a culture of safety.
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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 ArticleEthical medical treatment is an important aspect of healthcare that is affected by multiple influencing factors in, both private and public, medical organisations. By understanding and adapting the components of the health system to these influencing factors, healthcare can have better outcomes for patients and practitioners. Healthcare Administration for Patient Safety and Engagement provides emerging research on the theoretical and practical aspects of healthcare management for optimal patient care and communication. While highlighting topics, such as clinical communication, ethical dilemmas, and preventive medicine, this book will teach readers about the tools and applications of ethical treatment and hospital behaviour in both private and public medical organisations. This book is a resource for managers and employees of health units, physicians, medical students, psychology and sociology professionals, and researchers seeking current research on healthcare organisation and patient satisfaction.
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Content ArticleIn the light of the current national guidance to reduce the number of inpatient learning disability beds, a review was completed of the quality of lives of the people who had been former inpatients in Cornwall at the time of closure of the learning disability inpatient facilities almost 10 years before transforming care.
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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 ArticleThe West of England Academic Health Science Network has produced this webpage on caring for the deteriorating patient. One of the priorities identified by their Patient Safety Collaborative was the emergency management of the deteriorating patient, in particular identifying patients at risk and avoiding patient deterioration. This webpage includes examples and resources to help others implement similar changes and initiatives.
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Content ArticleIn this powerful blog, the author draws upon personal experience and insight to explain why she campaigns for carers and patients to have access to their own health records, and the difference this would make to patient safety. "Despite continued promises of access to all our health information by successive politicians and the talk of new gateways to our health information linking primary, secondary and social care, to people like us it seems as far away as ever. We hear about the Empowering the Person initiative, projects to improve data flows, data standards and all those new Apps but citizens like us are still as helpless as ever standing next to that stretcher in A/E without the very basic information to save our loved one’s life in a crisis."
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Content Article
Team of Teams: Fixing healthcare safety (June 2017)
PatientSafetyLearning Team posted an article in Systems
This article, from the Australian-based Patient Safe Network, argues that healthcare environments have become increasingly complex, existing error reporting systems based on traditional command structures are ineffective and we need to work as a ‘Team of Teams’. -
Content ArticleThis paper, published by the Canadian Journal of Surgery, suggests that the failure to systematically measure patient safety is the reason for limited progress. In addition to defining patient safety outcomes and describing their financial and clinical impact, the authors argue why the failure to implement patient safety measurement systems has compromised the ability to move the agenda forward. They also present an overview of how patient safety can be assessed and the strengths and weaknesses of each method and comment on some of the consequences created by the absence of a systematic measurement system.
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Content Article
Safety-II in practice (June 2017)
Claire Cox posted an article in Recommended books and literature
Safety-I is defined as the freedom from unacceptable harm. The purpose of traditional safety management is therefore to find ways to ensure this ‘freedom’. But as socio-technical systems steadily have become larger and less tractable, this has become harder to do. Resilience engineering pointed out from the very beginning that resilient performance – an organisation’s ability to function as required under expected and unexpected conditions alike – required more than the prevention of incidents and accidents. This developed into a new interpretation of safety (Safety-II) and consequently a new form of safety management. Safety-II changes safety management from protective safety and a focus on how things can go wrong, to productive safety and a focus on how things can and do go well. For Safety-II, the aim is not just the elimination of hazards and the prevention of failures and malfunctions but also how best to develop an organisation’s potentials for resilient performance – the way it responds, monitors, learns, and anticipates. That requires models and methods that go beyond the Safety-I toolbox. This book introduces a comprehensive approach for the management of Safety-II, called the Resilience Assessment Grid (RAG). It explains the principles of the RAG and how it can be used to develop the resilience potentials. The RAG provides four sets of diagnostic and formative questions that can be tailored to any organisation. The questions are based on the principles of resilience engineering and backed by practical experience from several domains. Safety-II in Practice is for both the safety professional and academic reader. For the professional, it presents a workable method (RAG) for the management of Safety-II, with a proven track record. For academic and student readers, the book is a concise and practical presentation of resilience engineering. -
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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News Article
Toddlers died after NHS 111 helpline said they were not in danger
Patient Safety Learning posted a news article in News
The NHS 111 helpline for urgent medical care is facing calls for an investigation after poor decision-making was linked to more than 20 deaths. Experts say that inexperienced call handlers and the software used to highlight life-threatening emergencies may not always be safe for young children. At least five have died in potentially avoidable incidents. Professor Carrie MacEwen, Chairwoman of the Academy of Medical Royal Colleges, said: “These distressing reports suggest that existing processes did not safeguard the needs of the children in these instances.” Since 2014 coroners have written 15 reports involving NHS 111 to try to prevent further deaths. There have been five other cases where inquests heard of missed chances to save lives by NHS 111 staff; two other cases are continuing and one was subject to an NHS England investigation. Read full story (paywalled) Source: The Times, 5 January 2020- Posted
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Content Article
Monitoring joint replacement surgery (August 2019)
Claire Cox posted an article in Research, data and insight
Thousands of people have joint replacement surgery every year and the National Joint Registry gathers together data on the outcomes of these surgeries. This allows surgeons and hospitals to monitor the success of their operations and ensure that the devices used are safe and effective. Individuals can also use the Registry to inform themselves better about the surgery which they are having. This short video explains what data is used and, more importantly, how it is used to ensure best outcomes for patients. -
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 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 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 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 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 ArticleThis chapter from Patient Safety and Quality: An Evidence-Based Handbook for Nurses describes a framework for understanding how human factors affect patient safety. It illustrates how different cumulative factors result in errors and suggests that nurses have a unique role to play in identifying problems and their causes. The authors highlight staff mindfulness as a tool to transform healthcare organisations into 'highly reliable organisations'.
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News ArticleChina has introduced a new law with the aim of preventing violence against medical workers. The announcement comes days after a female doctor was stabbed to death at a Beijing hospital. The law bans any organisation or individual from threatening or harming the personal safety or dignity of medical workers, according to state media. It will take effect on 1 June next year. Under the new law, those "disturbing the medical environment, or harming medical workers' safety and dignity" will be given administrative punishments such as detention or a fine. It will also punish people found illegally obtaining, using or disclosing people's private healthcare information. Read full story Source: BBC News, 29 December 2019
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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
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 ArticleIn accident investigation, the ideal is often to follow the principle “what-you-find-is-what-you-fix”, an ideal reflecting that the investigation should be a rational process of first identifying causes, and then implement remedial actions to fix them. Previous research has however identified cognitive and political biases leading away from this ideal. Somewhat surprisingly, however, the same factors that often are highlighted in modern accident models are not perceived in a recursive manner to reflect how they influence the process of accident investigation in itself. Those factors are more extensive than the cognitive and political biases that are often highlighted in theory. The purpose in this study from Lundberg et al. (published in Accident, Analysis and Prevention) was to reveal constraints affecting accident investigation practices that lead the investigation towards or away from the ideal of “what-you-find-is-what-you-fix”.
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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.
