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Showing results for tags 'System safety'.
Found 520 results
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Content Article
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 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 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 Article
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 ArticleModels and methods of work system design need to be developed and implemented to advance research in and design for patient safety. In this paper, Carayon et al. describe how the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, which provides a framework for understanding the structures, processes and outcomes in health care and their relationships, can be used toward these ends. An application of the SEIPS model in one particular care setting (outpatient surgery) is presented and other practical and research applications of the model are described.
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Content ArticleOver the last 20 years, the Royal College of Art has been a fierce proponent of the role of design to improve and save lives, leading the debate on the efficacy of design thinking when applied to real societal needs. Nowhere is this better exemplified than by its impact on healthcare and patient safety. With increasing pressure on the national healthcare system, public services and provisions have to meet ever more stringent financial, resource and efficiency objectives. The Royal College of Art has demonstrated how systems-led thinking and a design approach to understanding the user’s needs can effectively reduce infection and medical error, and improve treatment spaces and patient communication.
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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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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 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 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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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
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 ArticleIn this blog, Steven Shorrock reflects on why are we so resistant to change.
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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.
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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 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 Article
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 ArticleThis is a comprehensive collection of proven quality, service improvement and redesign tools, theories and techniques that can be applied to a wide variety of situations. You can search the collection alphabetically for a specific tool or browse groups of tools using one of four categories.
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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.
