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Showing results for tags 'System safety'.
Found 520 results
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Content ArticleAs the death toll from COVID-19 rapidly increases, the need to make a timely and accurate diagnosis has never been greater. Even before the pandemic, diagnostic errors (i.e., missed, delayed, and incorrect diagnoses) had been one of the leading contributors to harm in health care. The COVID-19 pandemic is likely to increase the risk of such errors. Based on emerging literature and collaborative discussions across the globe, Gandhi and Singh propose a new typology of diagnostic errors of concern in the COVID-19 era. These errors span the entire continuum of care and have both systems-based and cognitive origins. While some errors arise from previously described clinical reasoning fallacies, others are unique to the pandemic. We provide a user-friendly nomenclature while describing eight types of diagnostic errors and highlight mitigation strategies to reduce potential preventable harm caused by those errors.
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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 Article
Dirty Dozen and COVID-19 (webinar, May 2020)
Claire Cox posted an article in Coronavirus (COVID-19)
There are fears around maintaining personal safety whilst ensuring patient safety. Staff need to protect both themselves and their families at home. Equally, it is essential that staff feel supported in identifying risks and the potential for errors with a robust mechanism in place to reduce, eliminate or mitigate such risks. The Human Factors 'Dirty Dozen' is a concept developed by Gordon DuPont. He described elements that can act as precursors to accidents or incidents, or influence people to make mistakes. This webinar, from the Clinical Excellence Commission, looks at ways you can identify risks or 'hot spots' in your area of work and then discuss with your team at handover and huddles and plan strategies to reduce, eliminate or mitigate the risks -
Content ArticleIn this video Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, interviews Helen Hughes the Chief Executive of Patient Safety Learning, on how we can better share learning about reducing harm in healthcare. Helen shares the resources that are available through Patient Safety Learning and how those passionate about safety can get involved.
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Content ArticleEthical medical treatment is an important aspect of healthcare that is affected by multiple influencing factors in, both private and public, medical organisations. By understanding and adapting the components of the health system to these influencing factors, healthcare can have better outcomes for patients and practitioners. Healthcare Administration for Patient Safety and Engagement provides emerging research on the theoretical and practical aspects of healthcare management for optimal patient care and communication. While highlighting topics, such as clinical communication, ethical dilemmas, and preventive medicine, this book will teach readers about the tools and applications of ethical treatment and hospital behaviour in both private and public medical organisations. This book is a resource for managers and employees of health units, physicians, medical students, psychology and sociology professionals, and researchers seeking current research on healthcare organisation and patient satisfaction.
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Content ArticleThis conceptual article published in The Joint Commission Journal on Quality and Patient Safety describes the barriers and facilitators of adopting, implementing, and sustaining the Patient and Family Advisory Councils on Quality and Safety (PFACQS) model across a large, geographically diffuse health system. Successful strategies that emerged include active board engagement, co-creation and mentorship by experienced patient advocates to support enhanced engagement by local PFACQS community members, and clear alignment with and line of sight on organisational quality and safety goals. It concludes that implementing a robust network of PFACQS focused on improving quality and patient safety requires leadership commitment to transparency, as well as mutual respect and trust. Establishing clear guidelines, structures, and processes supports early adoption. Openness to continuous improvement and adaptations are important to programme success and contribute to programme sustainability.
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Content ArticleHuman factors are of pivotal importance to both patient safety and doctors’ wellbeing, says Peter Brennan and Tista Chakravarty-Gannon in this BMJ Opinion article. In this article they highlight what the General Medical Council (GMC) and other organisations are doing to support doctors to deliver good care for their patients through educational and support programmes, including the GMC’s new Professional Behaviours and Patient Safety Programmes (PBPS) being piloted across the UK. These programmes are designed to help improve doctors’ skills and confidence in addressing unprofessional behaviours. These initiatives should reduce medical error, improve patient safety and professional welfare, as well as enhancing team working.
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Content ArticleThe West of England Academic Health Science Network has produced this webpage on caring for the deteriorating patient. One of the priorities identified by their Patient Safety Collaborative was the emergency management of the deteriorating patient, in particular identifying patients at risk and avoiding patient deterioration. This webpage includes examples and resources to help others implement similar changes and initiatives.
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Content ArticleNHS Digital are proposing to make changes in how private healthcare data is collected and with whom it is shared. This will involve trialling the suitability of existing NHS systems for the collection of private healthcare data and bringing it into line with the standards, processes and systems used for NHS funded care. These proposed changes are based on feedback the Acute Data Alignment Programme (ADAPt) programme has already received from a wide range of stakeholders. Wider insight from private and NHS healthcare providers, clinicians, the public and other key stakeholders is now welcomed as part of this consultation to ensure that we address any significant issues and concerns which could prevent the successful implementation of these changes. We expect this survey will take no more than 20 minutes to complete but will vary depending on the level of detail in your response.
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Content ArticleIn this powerful blog, the author draws upon personal experience and insight to explain why she campaigns for carers and patients to have access to their own health records, and the difference this would make to patient safety. "Despite continued promises of access to all our health information by successive politicians and the talk of new gateways to our health information linking primary, secondary and social care, to people like us it seems as far away as ever. We hear about the Empowering the Person initiative, projects to improve data flows, data standards and all those new Apps but citizens like us are still as helpless as ever standing next to that stretcher in A/E without the very basic information to save our loved one’s life in a crisis."
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Content ArticleThis study, published in the British Medical Journal, found that current algorithm based smartphone apps cannot be relied on to detect all cases of melanoma or other skin cancers. Test performance is likely to be poorer than reported here when used in clinically relevant populations and by the intended users of the apps. The current regulatory process for awarding the CE (Conformit Europenne) marking for algorithm based apps does not provide adequate protection to the public.
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Team of Teams: Fixing healthcare safety (June 2017)
PatientSafetyLearning Team posted an article in Systems
This article, from the Australian-based Patient Safe Network, argues that healthcare environments have become increasingly complex, existing error reporting systems based on traditional command structures are ineffective and we need to work as a ‘Team of Teams’. -
Content ArticleThis paper, published by the Canadian Journal of Surgery, suggests that the failure to systematically measure patient safety is the reason for limited progress. In addition to defining patient safety outcomes and describing their financial and clinical impact, the authors argue why the failure to implement patient safety measurement systems has compromised the ability to move the agenda forward. They also present an overview of how patient safety can be assessed and the strengths and weaknesses of each method and comment on some of the consequences created by the absence of a systematic measurement system.
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Safety-II in practice (June 2017)
Claire Cox posted an article in Recommended books and literature
Safety-I is defined as the freedom from unacceptable harm. The purpose of traditional safety management is therefore to find ways to ensure this ‘freedom’. But as socio-technical systems steadily have become larger and less tractable, this has become harder to do. Resilience engineering pointed out from the very beginning that resilient performance – an organisation’s ability to function as required under expected and unexpected conditions alike – required more than the prevention of incidents and accidents. This developed into a new interpretation of safety (Safety-II) and consequently a new form of safety management. Safety-II changes safety management from protective safety and a focus on how things can go wrong, to productive safety and a focus on how things can and do go well. For Safety-II, the aim is not just the elimination of hazards and the prevention of failures and malfunctions but also how best to develop an organisation’s potentials for resilient performance – the way it responds, monitors, learns, and anticipates. That requires models and methods that go beyond the Safety-I toolbox. This book introduces a comprehensive approach for the management of Safety-II, called the Resilience Assessment Grid (RAG). It explains the principles of the RAG and how it can be used to develop the resilience potentials. The RAG provides four sets of diagnostic and formative questions that can be tailored to any organisation. The questions are based on the principles of resilience engineering and backed by practical experience from several domains. Safety-II in Practice is for both the safety professional and academic reader. For the professional, it presents a workable method (RAG) for the management of Safety-II, with a proven track record. For academic and student readers, the book is a concise and practical presentation of resilience engineering. -
Content Article
Why malnutrition matters in care homes? (October 2019)
Claire Cox posted an article in Community care
In this short video, Professor Martin Green explains why good nutrition in care homes is essential. He explains that screening patients before they come to the care home is a 'must do' rather than a 'nice to have'. This video was made for the National Nutrition awareness week in 2019. -
Content ArticleThe PRAISe project tests the hypothesis that, together, positive reporting and appreciative inquiry can be used as an intervention to facilitate behavioural change and improvement in the related areas of sepsis management and antimicrobial stewardship.
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Content ArticleExpanding on his previous commentary 'What does all this safety stuff have to do with me', Dan Cohen, Patient Safety Learning's Trustee and former Chief Medical Officer at DATIX, has written this article for the hub on personal responsibility in patient safe care.
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Content ArticleThis blog, written by Human Factors expert Stephen Rice and published by Forbes, looks at what healthcare can learn from the success of the aviation industry when it comes to safety.
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Content ArticleIn April 2017, Ian Paterson, a surgeon in the West Midlands, was convicted of wounding with intent, and imprisoned. He had harmed patients in his care. The scale of his malpractice shocked the country. There was outrage too that the healthcare system had not prevented this and kept patients safe. At the time of his trial, Paterson was described as having breached his patients’ trust and abused his power. In December 2017, the Government commissioned this independent Inquiry to investigate Paterson’s malpractice and to make recommendations to improve patient safety. This report presents the Inquiry’s methodology, findings and recommendations. More importantly, it tells the story of the human cost of Paterson’s malpractice and the healthcare system’s failure to stop him, and something of the enduring impact this has had on the lives of so many people.
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Monitoring joint replacement surgery (August 2019)
Claire Cox posted an article in Research, data and insight
Thousands of people have joint replacement surgery every year and the National Joint Registry gathers together data on the outcomes of these surgeries. This allows surgeons and hospitals to monitor the success of their operations and ensure that the devices used are safe and effective. Individuals can also use the Registry to inform themselves better about the surgery which they are having. This short video explains what data is used and, more importantly, how it is used to ensure best outcomes for patients. -
Content ArticleA powerful essay from Dr Joshua Lerner, an Emergency Room (ER) doctor who currently works at the Leominster campus of UMass Memorial Health Alliance-Clinton Hospital in the US...
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Content ArticleA&E is often seen as a service in crisis and is the focus of much media and political interest. But A&E is just the tip of the iceberg -- the whole urgent and emergency care system is complex, and surrounded by myth and confusion. This animation from The King's Fund gives a whistle-stop tour of how the system fits together and busts some myths about what's really going on -- explaining that the underlying causes go much deeper than just A&E and demand a joined-up response across all services.
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WHO: What is patient safety?
Claire Cox posted an article in WHO
The World Health Organization has produced a factsheet about patient safety, what it is and the burden of harm. -
Content ArticleJames Munro, Chief Executive of Care Opinion, argues that there is extraordinary, yet untapped value in patient feedback which is not being recognised in current policy and practice. His blog follows the launch of the National Institute of Healthcare Research's (NIHR) themed review on using patient feedback to improve care. Gathering feedback from people who use health services sounds like a simple and straightforward matter. Doesn’t everyone love feedback? The NIHR themed review Improving Care by Using Patient Feedback highlights that this is a topic beset by complexity, uncertainty and disagreement. It’s also an area which can provoke strong emotions both from those offering feedback, such as: “why isn’t anyone listening?” and those receiving it: “why am I being attacked when I work so hard?”.
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Content Article
Improving birthing pool design
Claire Cox posted an article in Maternity
Chartered Institute for Ergonomics and Human Factors has come together with industry and maternity units to redesign birthing pools to ensure they are safe and ergonomical for users. Read the attached case study.
