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Found 315 results
  1. News Article
    Patients are at risk of a missed cancer diagnosis due to a reliance on paper records, an NHS trust has admitted after a man died due to his tumour being overlooked. Michael Lane, 50, from Shrewsbury, was “failed” by Shrewsbury and Telford Hospital Trust, his family has said after his cancer scan result was misplaced leaving him with a growing kidney tumour for 10 years. The trust is yet to fully launch an electronic record system a year after an investigation into Mr Lane’s death warned other patients were at risk due to the gap in paper records. Mr Lane went into Shrewsbury and
  2. News Article
    Medical experts in cases involving doctors should have a mandatory duty to consider systems issues such as inadequate staffing levels to avoid them being scapegoated for wider failures, the Medical Protection Society (MPS) has said. The MPS, which supports the the professional interests of more than 300,000 healthcare professionals around the world, says medical expert reports focus on scrutinising the actions of the individual doctor even when failings are a result of the setting in which they work. Its report on the issue, shared with the Guardian before publication, points out tha
  3. News Article
    Health Minister Robin Swann has announced plans to improve the review process for serious adverse incidents (SAI) in Northern Ireland's health and social care system. The reviews take place after unintended incidents of harm and ensure improvements are made. The Regulation and Quality Improvement Authority (RQIA) was commissioned to examine the system's effectiveness. It found the process was not "sufficiently robust". In the RQIA report, the independent body found that "neither the SAI review process nor its implementation is sufficiently robust to consistently enable an unders
  4. Event
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    This free webinar from the Chartered Institute of Ergonomics and Human Factors explores how to apply human factors standards to the design of complex systems. You’ll find out about the benefits, pitfalls and challenges of using standards. You’ll hear about a step-by-step approach to finding solutions in a real-world example of a truly complex system. Register
  5. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on risk and behaviour to improve patient safety. Key learning ob
  6. Content Article
    The webinar starts with an introduction to the concept of near misses in healthcare and the challenges faced in learning from these near misses to improve safety. You will then hear how near misses are approached in rail and nuclear and how controls are developed in their processes. You will: Gain valuable insights from all three sectors: healthcare, rail and nuclear.Hear discussion about defining near misses with respect to controls.Learn how to build barriers in systems.
  7. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on errors and designing system-based solutions to improve patient saf
  8. News Article
    ECRI, the nation's largest patient safety organization, announces its unity with the United States' top safety experts in calling for a total systems approach to safety, a theme that was the central focus at the May 2022 Institute for Healthcare Improvement (IHI) Patient Safety Congress. During its annual convening of national safety leaders, IHI leadership announced its Declaration to Advance Patient Safety, an initiative focused on addressing safety from a total systems approach, as presented in the 2020 National Action Plan to Advance Patient Safety. "As a member of the National S
  9. Content Article
    To achieve the vision of health care that is safe, reliable, and free from harm, the Declaration to Advance Patient Safety calls for health care leaders to take collective and coordinated action by doing the following: Review the 17 recommendations and tactics to advance patient safety presented in the Institute for Healthcare Improvement (IHI) Safer Together: A National Action Plan to Advance Patient Safety, a report that harnesses the knowledge and insights of the National Steering Committee for Patient Safety members. Identify a senior sponsor and core team charged with deploy
  10. Content Article
    The white paper is based around nine principles. Their aim is to provide an easy-to-follow guide to human factors issues which need to be addressed when developing and implementing highly automated systems. The principles are: Understand the potential influence of other elements of the system on the automated components, as well as how the introduction of automation can affect those components. Automation must be seen in the context of the overall socio-technical system it exists in. Recognise that automation nearly always changes, rather than removes, the role of people in a sys
  11. Content Article
    This suite of documents includes: 1. The systems thinking journey What: Weaves systems thinking throughout the policy design process. Outlines how systems thinking complements existing guidance. Who: Designed as a first step into understanding systems thinking. 2. The systems thinking toolkit What: A step-by-step guide to 11 simple and accessible systems thinking tools. Includes illustrative examples and templates for each tool. Who: Designed for those who want to use systems thinking. 3. The systems thinking case study bank What:
  12. News Article
    RaDonda Vaught has spoken out about her criminal case for the first time last week in an exclusive interview with ABC News. Ms. Vaught, 38, was sentenced to three years of supervised probation on 13 May. She was convicted of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 after overriding an electronic medical cabinet as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. The error, in which vecuronium, a powerful paralyser, was administered instead of the sedative Versed, led to the death of 75-year-old C
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