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Showing results for tags 'System safety'.
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Content ArticleClive Flashman, Patient Safety Learning's Chief Digital Officer, shares his presentation slides from the Health Plus Care 2022 conference. The presentation slides include basic principles, how to involve the patient and public in design, key issues and Clive's ten top tips for digital health innovators.
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Content Article
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This constructive commentary reflects on two recent related publications, the Healthcare Safety Investigation Branch (HSIB) report, Variations in the delivery of palliative care services to adults, and an article from Sarcoma UK, Family insights from Dermot’s experience of sarcoma care. Drawing from these publications, Richard, brother-in-law of Dermot, gives a family perspective, calling for a more open discussion around how we can improve palliative care and sarcoma services, and why we must listen and act upon family and patient experience and insight.- Posted
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Content ArticleAt a recent Patient Safety Management Network meeting, Hester Wain, Head of Patient Safety Policy at NHS England, and Dr Matt Hill, Consultant Anaesthetist, University Hospitals Plymouth NHS Trust & National Clinical Advisor on Safety Culture at NHS England, presented slides on patient safety culture. Download the presentation slides from the attachment below.
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Event
Error and systems-based solutions to patient safety
Sam posted an event in Community Calendar
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 designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-based-solutions-patient-safety-masterclass or email frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org -
Event
Systems approach to patient safety including Human Factors
Sam posted an event in Community Calendar
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 designed to align with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-approach-patient-safety-masterclass or email frida@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code. -
Content ArticleOffering a concise yet comprehensive review of current practices in surgery and patient safety, Handbook of Perioperative and Procedural Patient Safety is a practical resource for practicing surgeons, anaesthesiologists, surgical nurses, hospital administrators, and surgical office staff. Edited by Drs. Juan A. Sanchez and Robert S. D. Higgins and authored by expert contributors from Johns Hopkins, it provides an expansive look at the scope of the problem, causes of error, minimising errors, surgical suite and surgical team design, patient experience, and other related topics.
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Content ArticleDo you ever feel like you keep addressing the same healthcare issue over and over again, only to have it resurface? It can be frustrating to focus on individual symptoms or parts of the system and not see any lasting change. This is where systems thinking comes in - a holistic approach that allows you to see the bigger picture and understand how different parts of a system interact with each other. Find out more in this blog from Tara Thornton for the FutureNHS Community.
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Content ArticleWhat exactly is machine learning and how is it being used in healthcare? Are machines always better than a person? How do we know? In this interview, Patient Safety managing editor, Caitlyn Allen asks these questions of artificial intelligence healthcare researcher Dr Avishek Choudhury.
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Content Article
Our heavily curated Instagram society has become very intolerant of error. In an era where everything we present is airbrushed, tweaked, filtered and polished before being released into the wild, we labour under the misapprehension that the real world is similar. We are sadly mistaken. The real world is messy, imperfect and error-prone. In this blog, Niall Downey talks about his book, Oops! Why Things Go Wrong, which explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, how it is sometimes actually quite efficient from a physiological standpoint and, most importantly, what we can do about it. -
Content ArticleStructured into four major sections this white paper, from the Chartered Institute of Ergonomics & Human Factors, helps you learn background information and context for the role of people in barrier systems. It sets out concerns about the way human and organisational factors are currently treated in some approaches to barrier management and in Bowtie Analysis in particular.
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"I am thirty miles south of London’s Gatwick Airport, the world’s busiest single-runway airport, when one of the seven Flight Control computers in my Airbus A320 aircraft fails . . . ’ So begins this pioneering book by Niall Downey – a cardio-thoracic surgeon who retrained to become a commercial airline pilot – where he uses his expertise in medicine and aviation to explore the critical issue of managing human error. With further examples from business, politics, sport, technology, education and other fields, Downey makes a powerful case that by following some clear guidelines any organisation can greatly reduce the incidence and impact of making serious mistakes. While acknowledging that in our fast-paced world getting things wrong is impossible to avoid completely, Downey offers a strategy based on current best practice that can make a massive difference. He concludes with an aviation-style Safety Management System that can be hugely helpful in preventing avoidable catastrophes from occurring. -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Dan talks to us about how his experiences as a paediatrician and military doctor have influenced his view of patient safety. He also describes the increasing complexity in healthcare systems and highlights the need for the Government to commit policy and resources to building and sustaining the NHS workforce. -
Content ArticleNew research showed how a national quality improvement programme called PReCePT (Preventing Cerebral Palsy in Pre Term labour) accelerated maternity units’ use of Magnesium sulphate for pre-term labour. The programme could serve as a blueprint for future efforts to get clinical guidelines into practice in other areas of care. The quality improvement programme involved training staff on the benefits of magnesium sulphate, and having a local midwife dedicated to encouraging and monitoring use of the medicine at their maternity unit. The programme was supported by Academic Health Science Networks (a regional and national organisation that encourages improvement and innovation in healthcare). This article from the National Institute for Health and Care Research provides a plain English summary and short film about the project.
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Content ArticleThe Cynefin® sense-making Framework, brainchild of innovative thinker Dave Snowden, empowers leaders across organizations, governments, and local communities, to work with uncertainty – to navigate complexity, create resilience, and thrive. As Snowden says, “The Framework guides us to make sense of the world, so that we can skillfully act in it.”
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Event
HSIB Safety Investigations Conference 2023
Patient Safety Learning posted an event in Community Calendar
The annual Healthcare Safety Investigation Branch (HSIB) conference agenda will cover: A focus on patient and family engagement. Sharing learning from HSIB national investigations – what has been learnt and how it can help support and improve local investigation practice. HSIB's maternity investigation programme work with families and trusts. This includes how HSIB implements learning from investigations and where the opportunities are to influence change. HSIB's work on Safety Management Systems. How HSIB's education programme is sharing learning to develop and improve local safety investigations. • An overview of HSIB's international work. Breakout sessions to share knowledge. You will also hear how the HSIB will form into the Health Services Safety Investigations Body and the Maternity and Newborn Safety Investigations (MNSI) function and how this may impact you. Register -
Content ArticleThis review published by the Modernisation Agency explores ‘social movements’ as a new way of thinking about large-scale systems change and assesses the potential contribution of applying this new perspective to NHS improvement programmes. This review has four objectives: to explore ‘social movements’ as a new way of thinking about large-scale systems change; to assess the potential contribution of applying this new perspective to NHS improvement; to enrich and extend NHS thinking in relation to large-scale, system wide change; and to begin to establish a research and evidence base to support the emergence of an improvement movement in the NHS.
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Content ArticleIn this article, published by the British Journal of Nursing, John Tingle, Lecturer in Law, discusses recently published patient safety reports including Patient Safety Learning's Mind the Implementation Gap. Tingle concludes: "The two reports discussed here (Patient Safety Learning, 2022; Martin et al, 2023) show that 10 years after Francis (2013) there has been some improvement in NHS patient safety. This can be termed ‘measured improvement’, but this has been no big-bang trajectory. The arguments advanced in both reports need to be discussed more widely, and they provide an excellent basis for patient safety reform."
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Content ArticleECRI is an independent non-profit that produces an annual list of Top 10 Patient Safety Concerns, and its list for 2023 includes a new emphasis on system safety. In this interview for the Betsy Lehman Center, two leaders at ECRI talk about the list and the current state of patient safety. Shannon Davila, ECRI’s Director of Total Systems Safety and Marcus Schabacker, President and CEO, discuss the need to address gaps in performance with a "total systems approach," the ongoing issue of health inequity and the patient safety risks associated with recent changes in state laws and guidance around obstetrics and maternity.
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Content ArticleIn January 2023, the Health and Social Care Select Committee opened an inquiry into Prevention. An interdisciplinary group of six academics, clinicians, and a coroner from the University of Oxford, the University of Birmingham, and London made a submission to that inquiry. They made their submission to the Prevention inquiry after reading and analysing more than 4,000 PFDs and working with coroners and bereaved families, which has highlighted that more must be done in health and social care to learn lessons from preventable deaths. Their full submission has now been published which included a table summarising 12 of their research studies relating to preventable deaths and providing recommendations. We have extracted the table which highlights several patient safety concerns and system safety recommendations.
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Content ArticleA patient safety intervention was tested in a 33-ward randomised controlled trial. No statistically significant difference between intervention and control wards was found. Authors of this study, published in BMJ Open, conducted a process evaluation of the trial and their aim in this paper was to understand staff engagement across the 17 intervention wards.
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Content ArticleThis study, published by Health Expectations, aimed to understand what people were doing during the first wave of the pandemic to protect the safety of their health, and the health of others from COVID‐19, and the resilience of the healthcare system.
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Content ArticleThis study in the Journal of Patient Safety outlines the development of the Leapfrog composite patient safety score. The researchers aimed to develop a composite patient safety score that provides patients, healthcare providers and healthcare purchasers with a standardised method to evaluate patient safety in general acute care hospitals in the United States. The study concluded that the composite score reflects the best available evidence regarding a hospital’s efforts and outcomes in patient safety.
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Content ArticleEnsuring organisations learn from patient safety incidents is a key aim for healthcare organisations. The role that human factors and systems thinking can have to enable organisations learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems. Investigation of incidents has previously been rooted in reductionist methodologies, for example, seeking to find the ‘root cause’ to individual incidents. While healthcare has embraced, in some contexts, the option for system-based methodologies—for example, SEIPS and Accimaps—these methodologies and frameworks still operate from a single incident perspective. It has long been acknowledged that healthcare organisations should focus on near misses and low harms with the same emphasis as incidents resulting in high harm. However, logistically, investigating all incidents in the same way is difficult.
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Content Article
NHS Patient Safety Syllabus v. 2.1 (June 2022)
Patient Safety Learning posted an article in Training & education
The Academy of Medical Royal Colleges and the University of Warwick have developed this NHS Patient Safety syllabus to complement it as the basis for education and training for staff throughout the NHS. -
Content Article
Rethinking healthcare as a safety-critical industry
Patient Safety Learning posted an article in Barriers
The discipline of ergonomics, or human factors engineering, has made substantial contributions to both the development of a science of safety, and to the improvement of safety in a wide variety of hazardous industries, including nuclear power, aviation, shipping, energy extraction and refining, military operations, and finance. It is notable that healthcare, which in most advanced societies is a substantial sector of the economy and has been associated with large volumes of potentially preventable morbidity and mortality, has not up to now been viewed as a safety critical industry. This paper from Robert L Wears proposes that improving safety performance in healthcare must involve a re-envisioning of healthcare itself as a safety-critical industry, but one with considerable differences from most engineered safety-critical systems. This has implications both for healthcare, and for conceptions of safety-critical industries.
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