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Showing results for tags 'System safety'.
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Content ArticleGreat Ormond Street Hospital NHS Foundation Trust is one of the world’s leading children’s hospitals, receiving 242,694 outpatient visits and 42,112 inpatient visits every year (figures from 2021/22). This paper seeks to provide an overview of the safety systems and processes Great Ormond Street Hospital has in place to keep patients, staff, and healthcare environments safe.
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Content ArticleDoctors At Work is a series of video podcasts hosted by Dr Mat Daniel. In this episode, Dr Gordon Caldwell shares his experiences of managing and preventing adverse events. He stresses the importance of creating a culture that encourages everyone to speak up. His top tips for preventing errors is to create systems, checklists and routines that ensure a focus on all aspects of care not just the obvious and urgent.
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Content ArticleIn this interview for inews, Professor Ted Baker, Chair of the new Health Services Safety Investigations Body (HSSIB), talks about the role of HSSIB in identifying system-wide safety issues in the NHS. He discusses why we need new approaches to tackling patient safety problems and outlines the importance of considering how the wider system leads to human error. He also talks about the impact of bullying on NHS staff, describing his own experiences as a junior doctor, which nearly led him to give up his career. He also describes the vital role of whistleblowers in making changes that genuinely improve patient safety, highlighting the problems currently facing staff who speak up for patient safety.
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- Investigation
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Content ArticleA series of LinkedIn articles on systems thinking from Phil Evans, Independent HealthTech Consultant.
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- System safety
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Content ArticlePatients treated and transported by Helicopter Emergency Medical Services (HEMS) are prone to both flight and medical hazards, but incident reporting differs substantially between flight organisations and healthcare, and the extent of patient safety incidents is still unclear. This study in the Journal of Patient Safety is based on in-depth interviews with eight experienced Norwegian HEMS physicians from four different bases from February to July 2020. The study aimed to explore the physicians’ experience with incident reporting and their perceived areas of risk in HEMS. The authors concluded that sparse, informal and fragmented incident reporting provides a poor overview of patient safety risks in HEMS. A focus on organisational factors and system responsibility is needed to further improve patient safety in HEMS, alongside research on environmental and contextual factors.
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Content ArticleThe Health Services Safety Investigations Body (HSSIB) was established by the Health and Care Act 2022 as a new non-departmental arm's length body, replacing the former Healthcare Safety Investigation Branch. HSSIB exists to help reduce patient harm by understanding the complex interactions that exist within healthcare that may lead to patient safety events occurring. In other safety critical industries, a safety management system (SMS) approach is used to help enable proactive assessments of risks, specification of how risks should be managed, and set clear lines of accountability and responsibility in addressing risks. This research paper published in the Journal of Patient Safety and Risk Management, shows how HSSIB has begun to explore how an SMS may operate in healthcare to help better equip the system to identify, respond, and proactively identify emerging and recurring concerns that may impact on the safety of patients.
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Content ArticleAs representatives of the European Patient Safety Foundation, the authors share with the wider patient safety community some current perspectives from across Europe. As the title suggests, in their view, the healthcare systems are dominated by the reality of having to deal with what are seen as multiple crises at the same time, and somehow keep patient safety on the agenda and come up with strategies and initiatives to make improvements. The situation is made even more complex by the fact that these crises take an additional toll on those responsible for delivering safe care, healthcare staff themselves, who already have to cope with difficult working conditions in normal times. This article was published by the Journal of Patient Safety and Risk Management.
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Content ArticleProfessor Joe McDonald, Principal Associate for health system collaboration for Ethical Healthcare Consulting, explains how the recent trial of Lucy Letby triggered both personal and professional rage – and the desire to do more to keep patients safe across the NHS.
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Content ArticleThe PreAccident Podcast is a bi-weekly discussion of the New View of safety, Systems Safety, Safety Differently and building a community of practice and thought. Hosted by Todd Conklin, this episode examines the idea that a tolerance for failure is a precondition to success.
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Content ArticleIn the UK and several other countries, including Norway, Australia and New Zealand, operators of safety-critical systems, such as nuclear power plants, public transportation systems and defence equipment, must develop a safety case to demonstrate that their systems are acceptably safe to operate. In these countries, the development, review and maintenance of safety cases are regulatory requirements. In the NHS in England, manufacturers of health information technology have been required to submit clinical safety cases since 2013. However, this is a domain with a narrow technological focus and limited organisational support. Mark Sujan and Ibrahim Habli discuss why they think safety cases would be a valuable addition to Safer Clinical Systems and patient safety practice?
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Content ArticleIn this essay for Interactions magazine, Donald A Norman argues that human-centred design has become such a dominant theme in design that it is now accepted by interface and application designers automatically, without thought, let alone criticism. He believes this as a dangerous state and his essay aims provoke thought, discussion and reconsideration of some of the fundamental principles of human-centred design.
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Content ArticleIn a report published in 2000 by the UK's Chief Medical Officer, it was estimated that 400 people in the UK die or are seriously injured each year in adverse events involving medical devices, and that harm to patients arising from medical errors occurs in around 10% of admissions—or at a rate in excess of 850 000 per year. The cost to the NHS in additional hospital stays alone is estimated at around £2 billion a year. This article examines system safety in healthcare and suggests a 20-item checklist for assessing institutional resilience (CAIR).
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- Resilience
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Content ArticleIn this series of blogs, Stephen Shorrock looks at different interpretations of the term 'human factors'. He outlines four key ideas that seem to exist, each of which has a somewhat different meaning and implications. The human factor Factors of humans Factors affecting humans Socio-technical system interaction
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Content ArticleIn this blog, Dr Nadeem Moghal looks at the recent case of a 30 year-old patient who died after a physician associate (PA) at her GP surgery failed to diagnose her with a pulmonary embolism. He outlines a recent debate about the role of PAs in general practice and why employing them has become an attractive option for GP partnerships, which run as businesses. He highlights the need for PAs to be adequately trained and supervised to ensure patient safety and argues that the role is here to stay as PAs play an important role in tackling gaps in the NHS workforce.
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Content Article
Designing in risk: Measuring safety part 3
NMacLeod posted an article in Improving patient safety
The relationship between management and the workforce, in very simplistic terms, can be considered one of reward in return for effort. The contracted effort is communicated through a roster. In organisations that have a continuous operation, blocks of effort are distributed to maintain the flow of output. The organisation of effort, then, is a legitimate function of management. Norman's previous blog looked at performance variability under normal conditions. In this blog, Norman looks at the impact of physiological states and how management’s organisation of effort degrades decision-making.- Posted
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Content ArticleIn this report authors make a case for the urgent need to improve communication within the NHS. We demonstrate how fundamental good communication is to the quality of care and treatment that people receive and the levels of trust and satisfaction they feel. They argue that communication and supporting administration should not be seen as a ‘nice to have’, but as fundamental to the functioning of the NHS. DEMOS delivered this work and this publication with our partners, the Patients Association and the PMA. Calls to action: 1. An expansion of the system of care coordinators and improving access to clinicians with oversight of all the care received by people with complex conditions. 2. An expansion of the system of care navigators in GP surgeries across the country, helping people to navigate complex systems and linking people up with the right services. 3. Improvements to the uptake and use of the NHS App through improved functionality and greater publicity Read the full report via the link below.
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Content ArticleIn a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk. In part 1 of this blog series, Norman suggested that measuring safety is problematic because the inherent variability in any system is largely invisible. Unfortunately, what we call safety is largely a function of the risks arising from that variability. In this blog, Norman explores how error might offer a pointer to where we might look.
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- Human error
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Content ArticleThe government recently published terms of reference for the Thirlwall Inquiry following the crimes committed by former neonatal nurse Lucy Letby while working for the Countess of Chester Hospital NHS Foundation Trust. As well as examining the detail of the offences, the inquiry will also probe whether the trust’s culture, management, governance structures and processes contributed to the failure to protect babies. In the wake of this tragedy, it became apparent that staff had sounded the alarm about Lucy Letby, but that their concerns were not acted on. The case has propelled the issue of NHS management structures and the regulation of managers back into the headlines and made it the subject of political debate.
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- Organisational culture
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Content Article
Can you measure safety? Part 1
NMacLeod posted an article in Improving patient safety
In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk. He argues that, to measure safety, we need to understand the creation of risk. In this first blog, Norman looks at the problems of measuring safety, using an example from aviation to illustrate his points.- Posted
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Content ArticleStephen Shorrock looks at how we use deficit-based taxonomies when describing incidents in healthcare and why neutralised taxonomies may be more flexible and useful.
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Content ArticleIn this article, Stephen Shorrock, Chartered Ergonomist and human factors specialist, shares some some insights on the concept of ‘human error and the idea of ‘honest mistakes’. He outlines the problem with thinking of errors as ‘causing’ unwanted events such as accidents, arguing that this approach ignores all of the other relevant ‘causes’, especially in high-hazard, safety-critical systems,
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Content ArticleThis article in the British Journal of Anaesthesia argues that the criminalisation of medical accidents leaves clinicians scared to report systemic causes and contributors to bad outcomes, removing a foundational pillar of patient safety. Looking at the case of RaDonda Vaught, a nurse who was found guilty of criminally negligent homicide for a fatal medication accident, the authors highlight the need to move away from seeing adverse incidents in healthcare as being easily avoided through greater attention, trying harder or adherence to rules. They call on healthcare organisations to learn from the case and argue that healthcare systems need to be collaboratively redesigned with a systems perspective.
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Content ArticleTo improve the safety and quality of healthcare, we try to understand and improve how healthcare providers accomplish patient care "work." This work includes synthesising information from a patient's history and physical examination or from a handoff, performing tests or procedures, administering medications and providing information so that patients can make the best choices for themselves. Sometimes this work flows very well and everyone is pleased with the results, but sometimes this work does not unfold in the way that was anticipated. This article, originally published in Pennsylvania Patient Safety Advisory, argues that efforts to improve healthcare work will not succeed without recognising that there is a difference between a theoretical construct of "work-as-imagined" and the reality of "work-as-done".
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Content ArticleThe National Patient Safety Improvement Programmes (SIPs) collectively form the largest safety initiative in the history of the NHS. They support a culture of safety, continuous learning and sustainable improvement across the healthcare system. SIPs aim to create continuous and sustainable improvement in settings such as maternity units, emergency departments, mental health trusts, GP practices and care homes. SIPs are delivered by local healthcare providers working directly with the National Patient Safety Improvement Programmes Team and through 15 regionally-based Patient Safety Collaboratives. The five National Patient Safety Improvement Programmes (NatPatSIP) are as follows: Managing Deterioration Safety Improvement Programme (ManDetSIP) Maternity and Neonatal Safety Improvement Programme (MatNeoSIP) Medicines Safety Improvement Programme (MedSIP) Adoption and Spread Safety Improvement Programme (A&S-SIP) Mental Health Safety Improvement Programme (MH-SIP) This report summarises the progress of the National Patient Safety Improvement Programmes.
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