Search the hub
Showing results for tags 'System safety'.
Found 520 results
-
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. -
Content ArticleThe use of health technology has grown exponentially in the past few decades, and the proliferation and complexity of this technology has led to new risks to patient safety. The Institute of Medicine (IOM) discussed this issue in their report, Health IT and Patient Safety: Building Safer Systems for Better Care, and concluded that achieving better health care requires “a robust infrastructure that supports learning and improving the safety of health IT.”
-
Content ArticleIn this commentary, I reflect on how we may all suffer from some degree of professional complacency. Healthcare professionals do not get up in the morning intending to harm anyone, but normal human liabilities can impair our performance. We may often fail to recognise environmental and situational risks, and, more importantly, to admit to our own personal liabilities and, thus, the risks we bring into the healthcare environment.
- Posted
- 2 comments
-
- (and 3 more)
-
Content ArticleThe digital transformation of medicine is perhaps best exemplified by computerised provider order entry (CPOE), which refers to any system in which clinicians directly place orders electronically, with the orders transmitted directly to the recipient. As recently as 10 years ago, most clinician orders were handwritten. Spurred by the 2009 federal HITECH Act and the accompanying Meaningful Use program, CPOE usage rapidly increased in inpatient and outpatient settings. The vast majority of hospitals in the US and most outpatient practices now use some form of CPOE. CPOE systems were originally developed to improve the safety of medication orders, but modern systems now allow electronic ordering of tests, procedures, and consultations as well.
-
Content ArticleToolkit for improving perinatal safety helps hospital labour and delivery units in the US improve patient safety, team communication, and quality of care for mothers and their newborns with an aim of decreasing maternal and neonatal adverse events resulting from poor communication and system failures.
-
Content ArticleAbout 40% of patient encounters in primary care offices involve some form of medical test. Studies of primary care offices consistently show that the process for managing tests is a significant source of error and patient harm. This step-by-step guide can help you increase the reliability of the testing process in your office.
-
Content ArticlePotentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies. This quality improvement study from Suliburk et al., published in JAMA Network Open, analysed the incidence of human performance deficiencies during the provision of surgical care to identify opportunities to enhance patient safety.
-
Content ArticleProfessor Alison Leary, Patient Safety Learning Trustee, is Chair of the Healthcare & Workforce Modelling at London South Bank University. In this interview with Patient Safety Learning, Alison discusses why she got involved in patient safety and what needs to change to enable the NHS to become a high performing organisation.
- Posted
- 1 comment
-
1
-
- (and 1 more)
-
Content ArticleEmergency departments (EDs) are under ever increasing pressure, with performance in winter reaching new lows every year; putting both patient safety and staff morale at risk. While a significant increase in resources, for both the NHS and social care, is clearly needed there are actions that health service leaders and boards can take to help their systems maintain safety and improve performance over winter.
-
Content Article
PSNet: Systems Approach
Claire Cox posted an article in In health care
The Patient Safety Network (PSNet) discuss a case of a 65 year old who went in for one operation, but ended up having a completely different operation. -
Content ArticleSir Stephen Moss, Patient Safety Learning Trustee, is the former Chairman of Mid Staffordshire Hospitals NHS Trust, following their damming Healthcare Commission report of 2009. In this interview with Patient Safety Learning, Sir Stephen tells us about lessons learnt and what more needs to be achieved to make the NHS one of the safest healthcare systems in the world. View video (15 minutes)
-
Content Article
Kathryn's story
Claire Cox posted an article in By patients and public
Kathryn recalls her personal experience of temporary paralysis and respiratory arrest after residual anaesthetic drugs were not flushed from her lines and cannulae following surgery. The video supports the Patient Safety Alert 'Confirming removal or flushing of lines and cannulae after procedures' issued by NHS Improvement in November 2017. More recently, the Healthcare Safety Investigation Branch (HSIB) have carried out an investigation looking at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines and made a series of recommendations. -
Content ArticlePatient Safety Learning speaks to Ben Tipney, Managing Director of MedLed and the hub topic lead in Human Factors, about how healthcare can achieve high performance and learn from other industries, including from the sports industry.
-
Content ArticleWe launched our green paper, 'A Patient-Safe Future’, in September 2018 for two reasons: first to help us develop our strategy and work programme to ensure we are focused on areas that will help make a real difference and, second, to develop a clear and consistent message about how the wider system needs to change to better support patient-safe care.
-
Content ArticleNHS England helps illustrate the benefits of business continuity planning and how the planning is implemented during a response. Case studies have been put together from various incident debrief reports from organisations to provide examples of approaches to incident reports and also allow identification of learning across organisations
-
Content ArticleThe review makes recommendations to support a more just and learning culture in the healthcare system. This rapid policy review into gross negligence manslaughter in healthcare was chaired by Professor Sir Norman Williams. The review was set up to look at the wider patient safety impact of concerns among healthcare professionals that simple errors could result in prosecution for gross negligence manslaughter, even if they happen in the context of broader organisation and system failings.
-
Content ArticleHealthcare Safety Investigation Branch (HSIB) report on the inadvertent administration of an oral liquid medicine into a vein. This report indicated the importance of using human factors in the investigation process. The investigation reviewed the effectiveness of the current processes for the storage of medicines, equipment design, and the prescribing, preparation, checking and administration of medication. It also considered the contextual, environmental and human factors that influenced the inadvertent administration of an oral solution into a vein. The effectiveness of current processes for implementation of local safety standards for invasive procedures was also considered. A human factors expert was involved in the investigation and a dedicated report was written based on the evidence reviewed, a reconstruction of the event and a simulation of what should have happened.
- Posted
- 1 comment
-
1
-
- (and 9 more)
-
Content Article
Systems Approach Resources (NES)
PatientSafetyLearning Team posted an article in Improving systems of care
Complex systems consist of many dynamic interactions between people, tasks, technology, environments (physical and social), organisational structures and arrangement and external factors, such as the influence of national policy or regulation. The nature of these interactions often results in unpredictable changes in system conditions (such as patient demand, staff capacity, available resources and organisational constraints) and goal conflicts (such as the frequent pressure to be efficient and thorough). To achieve success, people frequently adapt to these system conditions and goal conflicts. But rather than being planned in advance, these adaptations are often approximate responses to the situations faced at the time. Therefore, to understand patient safety or staff wellbeing (and other emergent outcomes) we need to look beyond the individual components of care systems to consider how outcomes (wanted and unwanted) emerge from interactions in, and adaptations to, everyday working conditions. Follow the link below to the NHS Education Scotland (NES) website to find out more about systems thinking and access systems approach resources. -
Content ArticleHuman Factors (Ergonomics) is the study of human activity (inside and outside of work). Its purpose as a scientific discipline is to enhance wellbeing and performance of individuals and organisations. A number of different definitions of Human Factors exist. The key principles are the interactions between you and your environment both inside and outside of work and the tools and technologies you use. This webpage from NHS Education Scotland (NES) provides links to a number of useful Human Factors resources used in healthcare. Topics include: Training Culture Leadership Systems Thinking Communication.
-
Content Article
NES: Safety culture discussion cards
PatientSafetyLearning Team posted an article in Good practice
Safety culture can be described as our: 1. Values (what is important) 2. Behaviours (the way we do things around here) 3. Beliefs (how things work). Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. NHS Education for Scotland (NES) has adapted these safety culture discussion cards (designed by EUROCONTROL) to help us to do this. Follow the link below to download the cards.- Posted
- 2 comments
-
1
-
- (and 3 more)
-
Content ArticleThe Chartered Institute of Ergonomics & Human Factors has issued today their White Paper on Adverse Events. This report states what good practice should be in incident investigation across all industries, including health and social care. The White Paper is designed to: 1. Help organisations understand a human factors perspective to investigating and learning from adverse events. 2. Provide key principles organisations can apply to capture the human contribution to adverse events. How organisations learn, and fail to learn, from adverse events is discussed.
-
Content ArticleProviding patients with access to electronic health records (EHRs) may improve quality of care by providing patients with their personal health information and involving them as key stakeholders in the self-management of their health and disease. With the widespread use of these digital solutions, there is a growing need to evaluate their impact, in order to better understand their risks and benefits and to inform health policies that are both patient-centred and evidence-based. The objective of this paper, published by BMJ Quality & Safety, was to evaluate the impact of sharing electronic health records (EHRs) with patients and map it across six domains of quality of care: patient-centredness effectiveness efficiency timeliness equity safety.
-
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”.
-
Content ArticleThis month’s Letter from America looks at perspectives examining collective responses to the COVID-19 pandemic through a systems analysis lens. Letter from America is the latest in a Patient Safety Learning blog series highlighting new accomplishments in patient safety from the United States.
