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Showing results for tags 'System safety'.
Found 520 results
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Content ArticleComplexity science offers ways to change our collective mindset about healthcare systems, enabling us to improve performance that is otherwise stagnant, argues Jeffrey Braithwaite in this BMJ article. Jeffrey is a professor of health systems research and president elect of the International Society for Quality in Health Care.
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Content ArticleJo Wailling is a registered nurse and research associate with the Diana Unwin Chair in Restorative Justice, Victoria University of Wellington. Jo presented on restorative practice at the Commission’s mental health and addiction (MHA) quality improvement programme workshop held in Wellington on 26 June for mental health and addiction leaders. This blog is a continuation of that presentation.
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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 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 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 ArticleSir Liam Donaldson's presentation slide at the High Level Forum, Africa Patient Safety Initiative, Cape Town, South Africa 24- 25 October 2019.
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Content Article
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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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 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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Community PostHi everybody This is Jaione from Spain (we are in the North, Basque Region) and i am a nurse working in collaboration with the Patient Safety Team in our local NHS (Basque Health Service). First of all, I would like to congratulate the team for this hub which i think is a wonderful idea. Secondly, i would like to apologize for the language, since, although i lived in England many years ago, that is not the case anymore and I'm afraid i don't speak as well as I used to. I would like to comment a problem that we encounter very often in our organization which is related to patient's regular medications when they are admitted to hospital. We do have online prescriptions for both acute and community settings but the programs don't really speak to each other so, for example, if I take a blood pressure pill everyday and i get admitted into hospital, chances are that my blood pressure tablet won't get prescribed during my in-hospital stay. The logical thing to do would be to change both online systems so they communicate to each other, but that's not possible at the moment. I wanted to ask whether other systems have the same problem and, if so, if there is any strategy implemented to alleviate this issue. I hope i have expressed myself as clearly as possible. Thanks very much once more for this hub! Kind regards Jaione
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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. -
Community PostHi I have been working in a presentation we are giving at ASPiH in November around the work we have done using simulation to test systems and processes. we have done this in two ways. Firstly as a by-product of an educational in situ simulation in s clinical environment where a latent threat has been identified. In this case we will work with the area in looking at just what contributes to the threat and ways that may help. The second way (and with my HF head on, more exciting) has been setting out to test a process. We have done this several times now and have had some real successes in demonstrating the work as done v work as imagined theory. has anyone else used simulation in this way? looking forward to your replies. Phil
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Content ArticleHealth IT (HIT) systems are increasingly becoming a core infrastructural technology in healthcare. However, failures of these systems, under certain conditions, can lead to patient harm and as such the safety case for HIT has to be explicitly made. This study from Habli et al., published in Safety Science, focuses on safety assurance practices of HIT in England and investigates how clinicians and engineers currently analyse, control and justify HIT safety risks. Two areas of strength were identified: establishment of a systematic approach to risk management and close engagement by clinicians; and two areas for improvement: greater depth and clarity in hazard analysis practices and greater organisational support for assuring safety. Overall, the dynamic characteristics of healthcare combined with insufficient funding have made it challenging to generate and explain the safety evidence to the required level of detail and rigour. Improvements in the form of practical HIT-specific safety guidelines and tools are needed. The lack of publicly available examples of credible HIT safety cases is a major deficit. The availability of these examples can help clarify the significance of the HIT risk analysis evidence and identify the necessary expertise and organisational commitments.
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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 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.”
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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 ArticleRather than being a static property of hospitals and other healthcare facilities, safety is dynamic and often on short time scales. In the past most healthcare delivery systems were loosely coupled—that is, activities and conditions in one part of the system had only limited effect on those elsewhere. Loose coupling allowed the system to buffer many conditions such as short term surges in demand. Modern management techniques and information systems have allowed facilities to reduce inefficiencies in operation. One side effect is the loss of buffers that previously accommodated demand surges. As a result, situations occur in which activities in one area of the hospital become critically dependent on seemingly insignificant events in seemingly distant areas. This tight coupling condition is called “going solid”. Rasmussen’s dynamic model of risk and safety can be used to formulate a model of patient safety dynamics that includes “going solid” and its consequences. Because the model addresses the dynamic aspects of safety, it is particularly suited to understanding current conditions in modern healthcare delivery and the way these conditions may lead to accidents.
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Content ArticlePresentation from Dr Richard Cook at the Velocity 2012 conference. Dr Cook is the Professor of Healthcare Systems Safety and Chairman of the Department of Patient Safety at the Kungliga Techniska Hogskolan (the Royal Institute of Technology) in Stockholm, Sweden. He is a practicing physician, researcher and educator.
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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.
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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.
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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.
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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.
