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Found 161 results
  1. Content Article
    The use of artificial intelligence (AI) in patient care can offer significant benefits. However, there is a lack of independent evaluation considering AI in use. This paper from Sujan et al., published in BMJ Health & Care Informatics, argues that consideration should be given to how AI will be incorporated into clinical processes and services. Human factors challenges that are likely to arise at this level include cognitive aspects (automation bias and human performance), handover and communication between clinicians and AI systems, situation awareness and the impact on the interaction with patients. Human factors research should accompany the development of AI from the outset.
  2. Content Article
    In this talk, Rob Hackett, director of The PatientSafeNetwork, takes a look at the medical error problem, why it exists, why it persists, what we can do through working together to overcome it and create the best environment for patient care.
  3. Content Article
    This issue of Hindsight includes articles on: Malicious compliance by Sidney Dekker Can we ever imagine how work is done? by Erik Hollnagel Safety is in the eye of the beholder by Florence-Marie Jegoux, Ludovic Mieusset and Sébastien Follet I wouldn't have done what they did by Martin Bromiley
  4. Content Article
    About the authors Robert W. Proctor is a distinguished professor of Psychological Sciences at Purdue University. He is a fellow of the American Psychological Association, Association for Psychological Science, and the Human Factors and Ergonomics Society, and recipient of the Franklin V. Taylor Award for Outstanding Contributions in the Field of Applied Experimental/Engineering Psychology from Division 21 of the American Psychological Association in 2013. He is co-author of Stimulus-Response Compatibility: Data, Theory and Application, Skill Acquisition & Training, and co-editor of Handbook of Human Factors in Web Design. Trisha Van Zandt is a professor of Psychology at The Ohio State University. She is a member of the Society for Mathematical Psychology, of which she was President in 2006-2007, and the American Statistical Association. She has received multiple research grants from the National Science Foundation and the Presidential Early Career Award for Scientists and Engineers in 1997. She is co-author of review chapters "Designs for and Analyses of Response Time Experiments" in the Oxford Handbook of Quantitative Methods and "Mathematical Psychology" in the APA Handbook of Research Methods in Psychology.
  5. Content Article
    Building on its successful predecessors, the third edition of The Field Guide to Understanding ‘Human Error’ will help you understand a new way of dealing with a perceived 'human error' problem in your organisation. It will help you trace how your organisation juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at all levels of your organisation, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding 'Human Error' will help you understand: how to move beyond 'human error' how to understand accidents how to do better investigations how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organisation face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organisation.
  6. Content Article
    Currently, stillbirths, neonatal deaths and brain injuries occurring due to incidents in labour are investigated at a local level. The Each baby counts project team will, for the first time, bring together the results of these local investigations to understand the bigger picture and share the lessons learned. From 2015, they began collecting and analysing data from all UK units to identify lessons learned to improve future care. They will then be able to make recommendations on how to improve practice at a national level. This page brings together all of the information and resources about the Each baby counts programme.
  7. Content Article
    Colour is a hallmark of Autumn across the US. A more spectacular set of colours, in a variety of shapes and sizes, paint the sky at daybreak every October in New Mexico. The Albuquerque International Balloon Fiesta is the largest gathering of its kind. In 2019, its 48th year, the fiesta hosted 550 hot air balloons, 650 pilots and entertained close to 900,000 visitors. The event holds a place on the bucket lists of travellers around the world. It is hard to describe the feeling of glee standing amid a mass ascension until you’ve been there amongst the early morning crowds. You might think it’s all fun, funnel cakes and floating but—like any aviation activity—ballooning entails risk. Make no mistake, the balloonists and their teams, the organisers, law enforcement, and even participants play a role in the safety of the event. Before sunrise each day, the “dawn patrol” of 8–10 hot air balloonists lift off. These experienced pilots gage the safety of the sky prior to the authorities giving the signal for the assent to begin. Only after that, does the wave after wave of multiple balloons unpack, gear up, inflate and take off from the field. Crews mull about, patiently navigating their designated space amongst onlookers and their cameras to get ready for flight. They implement standard procedures to safely gear-up for flight. Healthcare, too, prepares teams for complex situations to ensure safety through standardisation and practice. The US healthcare accreditation agency, the Joint Commission, shared insights on reducing maternal harm due to postpartum haemorrhaging that summarises best practices centered on readiness, recognition, response and reporting to support systems learning. Stanford Medicine in California recently held a series of “dress rehearsals” prior to opening a new hospital. The test of the space gave clinicians, administrators and patient advisors a chance to make sure conditions were right for a safe opening day. The fiesta organisers also deploy tactics to learn from what doesn’t go well. They use technology to gather input from crews and the public to identify areas for improvement. Traffic into the 360-acre launch site creates ineffective and potentially dangerous situations given the swell of people arriving in town. Attendees almost double the size of the city for the 10-day event. Public input gathered online helped planners to redesign this year’s park and ride shuttle system after it failed in 2018 to reliably get people to the festival. Hospitals also use information technology to learn how to improve the safety of the care experience. Researchers in Washington State developed a 4-step model built on inpatient experiences with undesirable events. They used patient and family knowledge to design informatics solutions that engage patients as contributors to safety. The model supports raising awareness of problems, encouraging prevention actions, managing emotional harms and reducing barriers to reporting .A rare situation stalled the festival this year: fog. Yes, fog is not something New Mexican’s encounter often but it shut down opening day morning—none of the balloonists could take off. This unique occurrence would have been all the more problematic had teams not heeded safety advice in this less-than-ideal situation. Practices and protocols keep patients safe too but only if they are followed. A unique set of circumstances led to the death of a patient awaiting care in a Pennsylvania emergency department. Protocols weren’t followed limiting situation awareness, communication and process completion. Balls were dropped and the results were tragic. Complex systems can manifest unintended consequences from strategies designed to protect people. Balloon fiesta has its share of mishaps. Pilots end up in the Rio Grande, drift into powerlines, bones get broken and, rarely, lives are lost. The expert crews mean well but failures happen. A nurse in Tennessee who made a medication mistake that resulted in patient death was charged criminally. While lawmakers may feel this is a just approach, it is a threat to healthcare transparency. A series of incidents involving misdiagnosis of child abuse is raising concerns in the US. While specialised paediatricians can readily identify patient conditions that indicate abuse, sometimes those judgements are made in error. The decisions made to protect children instead accuse innocent parents or family members of harm. The safe flight of those families then tumbles to the ground. The pace is back to normal in Albuquerque. Balloons still float above us in the morning and afternoon—'tis the season. They brighten the clear blue skies with the Sandia mountains as a backdrop. But you can bet that what did go wrong this year will be folded into the event planning so all that participate in the 2020 festival will be as safe as possible.
  8. Content Article
    The transport of the ICU patient is a complicated process and can lead to patient harm. In the Department of Critical Care Medicine, Calgary Health Region, staff underestimated the risks of intrahospital transport, which led to the two adverse events mentioned above. This article published in Healthcare Quarterly has describes the development of an ICU patient transport decision scorecard to support the safe transport of ICU patients for diagnostic testing. The scorecard is a visual assessment tool. Each item on it is a decision point and a simple reminder to ensure that appropriate resources are available prior to transport. Outcome measures have been added to begin to measure the effectiveness of the tool. Several lessons were learned from the development of this tool: the need to form a subgroup with team members from all sites and disciplines to ensure early buy-in; the involvement of a human factors expert to make the tool easier to use; and the need to continuously retest the tool using PDSA cycles.
  9. Content Article
    Minimal Information Model: The WHO Minimal Information Model for Patient Safety is a simple tool which contains the core data categories required for analysis, that can be used by any institution that is looking to set up, or improve, their reporting and learning system. International Classification for Patient Safety: The Conceptual Framework for the International Classification for Patient Safety, developed in 2009, defines and harmonises patient safety concepts into an internationally agreed classification.
  10. Content Article
    Presented by Sidney Dekker, Safety Differently: The Movie tells the stories of three organisations that had the courage to devolve, de-clutter, and decentralise their safety bureaucracy. It is a story of hope; of rediscovering ways to trust and empower people and of reinvigorating the humanity and dignity of actual work.
  11. Content Article
    The findings of this paper show that safety lapses in primary and ambulatory care are common. About half of the global burden of patient harm originates in primary and ambulatory care, and estimates suggest that nearly four out of ten patients experience safety issue(s) in their interaction with this setting. Safety lapses in primary and ambulatory care most often result in an increased need for care or hospitalisations. Available evidence estimates the direct costs of safety lapses – the additional tests, treatments and health care – in primary and ambulatory care to be around 2.5% of total health expenditure. Safety lapses resulting in hospitalisations each year may count 6% of total hospital bed days and more than 7 million admissions in the OECD.
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