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Showing results for tags 'System safety'.
Found 518 results
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Content ArticleTransport of patients from the intensive care unit (ICU) to another area of the hospital can pose serious risks if the patient has not been assessed prior to transport. The Department of Critical Care Medicine, Calgary Health Region, experienced two adverse events during transport. A subgroup of the Department's Patient Safety and Adverse Events team developed an ICU patient transport decision scorecard. This tool was tested through Plan-Do-Study-Act cycles and further revised using human factors principles. Staff, especially novice nurses, found the tool extremely useful in determining patient preparedness for transport.
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Content ArticleThe use of artificial intelligence (AI) in patient care currently is one of the most exciting and controversial topics. It is set to become one of the fastest growing industries, and politicians are putting their weight behind this, as much to improve patient care as to exploit new economic opportunities. In 2018, the then UK Prime Minister pledged that the UK would become one of the global leaders in the development of AI in healthcare and its widespread use in the NHS. The Secretary for Health and Social Care, Matt Hancock, is a self-professed patient registered with Babylon Health’s GP at Hand system, which offers an AI-driven symptom checker coupled with online general practice (GP) consultations replacing visits at regular GP clinics.
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Content ArticleAthough considerable progress has been made with comparing human factors in a safety critical industry to human factors in healthcare, it is clear that the variabilities found in healthcare are far more complex than industrial situations. While comparing human factors in the operating room and intensive care unit with systems from the airline, maritime and off shore industries is appropriate, Geoff Cardwell in this article discusses why a generalised approach to apply human factors in the routine activities of hospitals is needed and the nuclear industry is more appropriate for this wider context, where the ALARA (As Low As Reasonably Achievable) principles is used for managing radiation exposure. This approach can be compared to minimising the exposure to infection and superbugs in hospitals as well as reducing process failure where human factors are involved.
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Content ArticleTo Err Is Human breaks the silence that has surrounded medical errors and their consequence – but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda – with state and local implications – for reducing medical errors and improving patient safety through the design of a safer health system.
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Content ArticleThe purpose of the International Classification for Patient Safety (ICPS) is to enable categorisation of patient safety information using standardized sets of concepts with agreed definitions, preferred terms and the relationships between them being based on an explicit domain ontology (e.g., patient safety). The ICPS is designed to be a genuine convergence of international perceptions of the main issues related to patient safety and to facilitate the description, comparison, measurement, monitoring, analysis and interpretation of information to improve patient care. Download visual representation of the framework
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Content ArticleHindSight is a magazine produced by the Safety Improvement Sub-Group (SISG) of EUROCONTROL. It is produced for Air Traffic Controllers and is issued by the Agency twice a year. Its main function is to help operational air traffic controllers to share in the experiences of other controllers who have been involved in ATM-related safety occurrences. The current Editor in Chief is Dr Steven Shorrock.
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Royal Pharmaceutical Society: Ward round checklist example
Claire Cox posted an article in Handover
Ward rounds happen each day with your clinical team. In order for them to standardise the way they are conducted East Lancashire Hospital NHS Trust has designed a ward round check list, this is to ensure that everyone gets the same safety checks and important discussions are had for every patient. -
Content ArticleIn 2016, medical error was reported as the third greatest cause of death. The introduction of ergonomic science into healthcare will help overcome this; however, healthcare frameworks are resistant to change, particularly ergonomic initiatives. The PatientSafe Network exists to address this.
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Content ArticleBuilding on published patient safety research literature, this paper from the OECD, aims to broaden the existing knowledge base on safety lapses occurring in primary and ambulatory care settings.
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Content Article"Among many other opportunities created by the launch of the World Alliance for Patient Safety is the hope that one day the learning from the inadvertent death of a patient in a hospital in one country could save the lives of many others around the world." In his paper, Sir Liam Donaldson (Chair of the WHO World Alliance for Patient Safety at the time) talks about the importance of global collaboration for patient safety.
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Content ArticleIn a new instalment of the Profiles in Improvement series from the US based Institute for Healthcare Improvement (IHI), Patricia McGaffigan describes her healthcare journey and why the safety movement needs a “reboot.”
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Content ArticleMaternity care continues to be associated with avoidable harm that can result in serious disability and profound anguish for women, their children, and their families, and in high costs for healthcare systems. To understand how to make maternity care safer, we must first understand what makes a maternity unit safe. Rather than focus on what goes wrong, this study from THIS.Institute focuses on what needs to go right by studying one high-performing maternity unit, located in Southmead Hospital in Bristol, UK.
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WHO: Patient Safety – Making health care safer (May 2017)
PatientSafetyLearning Team posted an article in WHO
Patient Safety: Making health care safer illustrates the importance of safe care for everyone, what the burden and impact of unsafe care is, and WHO’s approach to tackling the issue of unsafe care. The brochure also contains a comprehensive collation of key WHO materials and activities in to generate improvements at the front line. -
Content ArticleAbout one in ten patients are harmed during health care. Published on the OECD Library website, this paper estimates the health, financial and economic costs of this harm. Results indicate that patient harm exerts a considerable global health burden. The financial cost on health systems is also considerable and if the flow-on economic consequences such as lost productivity and income are included the costs of harm run into trillions of dollars annually. Because many of the incidents that cause harm can be prevented, these failures represent a considerable waste of healthcare resources, and the cost of failure dwarfs the investment required to implement effective prevention.
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Letter from America: a Fall tradition to learn from
lzipperer posted an article in Letter from America
‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery. -
Content ArticlePublished in Systematic Reviews, this paper looks at how organisations need to systematically identify contributory factors (or causes) which impact on patient safety in order to effectively learn from error. Investigations of error have tended to focus on taking a reactive approach to learning from error, mainly relying on incident-reporting systems. Existing frameworks which aim to identify latent causes of error rely almost exclusively on evidence from non-healthcare settings. In view of this, the Yorkshire Contributory Factors Framework (YCFF) was developed in the hospital setting. Eighty-five percent of healthcare contacts occur in primary care. As a result, this review will build on the work that produced the YCFF, by examining the empirical evidence that relates to the contributory factors of error within a primary care setting.
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Is there a ‘best measure’ of patient safety?
Claire Cox posted an article in Research papers
Despite consensus that preventing patient safety events is important, measurement of safety events remains challenging. This is, in part, because they occur relatively infrequently and are not always preventable. There is also no consensus on the ‘best way‘ or the ‘best measure’ of patient safety. Borzecki and Rosen discuss what the 'best' measure for patient safety is in this Editorial published in BMJ Quality and Safety. -
Content ArticleOver 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. The cost of compliance and bureaucracy can be mind-boggling – up to 10% of GDP, with every person working some 8 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.
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Content ArticleThe Multi-professional Patient Safety Curriculum Guide (2011) was developed by the World Health Organization to assist in the teaching of patient safety in universities and schools in the fields of dentistry, medicine, midwifery, nursing and pharmacy. It also supports the on-going training of all healthcare professionals.
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Content ArticleContinuous improvement of patient safety: A case for change in the NHS synthesises the lessons from the Health Foundation’s work on improving patient safety.
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Content ArticleSteven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. The term 'human factor' is rarely defined, but people often refer to reducing it. In this blog, Steven asks what are we actually reducing?
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Content ArticleHealthcare systems are under stress as never before. An ageing population, increasing complexity and comorbidities, continual innovation, the ambition to allow unfettered access to care and the demands on professionals contrast sharply with the limited capacity of healthcare systems and the realities of financial austerity. This tension inevitably brings new and potentially serious hazards for patients and means that the overall quality of care frequently falls short of the standard expected by both patients and professionals. The early ambition of achieving consistently safe and high-quality care for all1 has not been realised and patients continue to be placed at risk. In this paper published in BMJ Quality & Safety, Amalberti and Vincent discuss the strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to.
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Content ArticleA report from the WISH patient safety forum held in 2015 about transforming patient safety using a sector-wide systems approach. WISH is a global healthcare community dedicated to capturing and disseminating the best evidence-based ideas and practices.
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Content Article
Work as is done, work as imagined
Anonymous posted an article in Florence in the Machine
This blog highlights: The juxtaposition of how work is carried out by healthcare staff compared to the work that policy makers are 'imagining' healthcare workers are doing. The need for healthcare staff to be part of patient safety solutions. -
Content Article
Freedom to Speak Up Guardian job description (March 2018)
Claire Cox posted an article in Speak Up Guardians
This is the Freedom to Speak Up Guardian job description. Use it for reference or for a template to advertise for a Freedom to Speak Up Guardian in you trust/sector.
