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Showing results for tags 'System safety'.
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Content Article
Responding to patient alarms in single patient rooms
katepym posted an article in Equipment and facilities
This survey for health and care staff looks at how quickly staff are aware of alarms emitted by bedside monitoring equipment in single patient rooms, and their ability to respond. Doors to single patient rooms are often kept shut for long periods of time for reasons of privacy, dignity and (at the moment especially) infection control. With the UK Government targeting a growth in the proportion of NHS hospital rooms which have a single bed, is this a risk to the health and wellbeing of patients? This is not a specific issue where data is collected, so an online survey has been created to gather feedback and opinions.- Posted
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- Communication problems
- Devices
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Content ArticleIn this opinion piece for the BMJ, David Oliver, a consultant in geriatrics and acute general medicine, draws lessons from the Grenfell Tower disaster and subsequent public inquiry. 72 people lost their lives in the fire that destroyed Grenfell Tower in 2017. Evidence to the public inquiry has shown that several residents had raised concerns about the building's safety over many years, and that architects, building contractors, and providers and fitters of cladding material had also expressed concerns about the safety of the exterior cladding used on Grenfell Tower. David Oliver highlights that had these concerns been listened to and acted on, the disaster could have been avoided and many lives saved. He draws parallels with concerns being raised by patients about the safety of the healthcare system and highlights the role of staff in repeatedly raising and keeping a record of concerns. He states that NHS leaders must create a culture where no one is afraid to speak out and act to mitigate safety issues. Leaders must expect to be held accountable for their response - or lack of response - to safety issues raised.
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- Patient safety strategy
- Patient engagement
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Content ArticleThe Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models provide a framework for integrating Human Factors and Ergonomics (HFE) in health care quality and patient safety improvement. As care becomes increasingly distributed over space and time, the “process” component of the SEIPS model needs to evolve and represent this additional complexity. In this paper, Carayon et al. review different ways that the process component of the SEIPS models have been described and applied. Carayon et al. propose the SEIPS 3.0 model, which expands the process component, using the concept of the patient journey to describe the spatio-temporal distribution of patients’ interactions with multiple care settings over time. This new SEIPS 3.0 sociotechnical systems approach to the patient journey and patient safety poses several conceptual and methodological challenges to HFE researchers and professionals, including the need to consider multiple perspectives, issues with genuine participation, and HFE work at the boundaries.
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- Human factors
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Content ArticleThe UK has fewer acute hospital beds relative to its population than many comparable health systems, and the Covid-19 pandemic has had a significant impact on their availability and use. This article by The King's Fund illustrates long-term trends in hospital beds, using 2019-20 data from before the pandemic as the most recent comparator. However, where data is available for 2020/21, the authors have included this for information and to show the impact of the pandemic.
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- Equipment shortages
- Pandemic
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Content ArticleThe resilience of health systems and cooperation between Member States have become particularly important during the COVID-19 pandemic. On the occasion of the French Presidency of the European Union (FPEU) 2022, the European Observatory on Health Systems and Policies and the General Directorate for HealthCare Services of the French Ministry of Health have worked together to produce this special issue of Eurohealth to better understand how health systems have responded to the health crisis and to draw lessons for improving resilience of health systems. (Available in both English and French.)
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- Policies
- System safety
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Content ArticleThis article in the British Journal of General Practice examined GP perspectives and concerns about safeguarding during the Covid-19 pandemic, focusing on the challenges and opportunities created by remote consultation. GPs interviewed for the study expressed concern about missing observational information during remote consultations, with pooled triage lists seen as further weakening safeguarding opportunities. They were also worried that conversations might not be private or safe. Remote consultations were seen as more ‘transactional’, with reduced opportunities to explore ‘other reasons’ including new safeguarding needs. Remote consultation was seen as more difficult and draining and associated with increased GP anxiety and reduced job satisfaction. However, GPs also recognised opportunities that remote consulting offers, including providing more opportunities to interact with vulnerable patients.
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- GP
- Primary care
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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- Posted
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- Human factors
- Human error
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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.- Posted
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- System safety
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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- Posted
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- Investigation
- Patient engagement
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Event
SEIPS masterclass in maternity
Patient-Safety-Learning posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply the Systems Engineering for Patient Safety (SEIPS) approach. This 2.5 hour masterclass will focus on using SEIPS in maternity. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. The course costs £50 per person. Pre and post class materials will be provided. Book a place- Posted
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- Maternity
- Human factors
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EventThis one-day virtual course is suitable those engaged or interested in patient safety, quality improvement & service delivery. On this interactive virtual course we will explore how human factors and ergonomics impact everyday working practices & patient safety. This material aligns with key focuses of the National Patient Safety Strategy, PSIRF & several domains of the National Patient Safety Syllabus 2.0. This course is equivalent to 6 hours of education. It will show you how to take a systems approach to respond to patient safety investigations using the SEIPS Model. Participants have the opportunity to practically apply SEIPS to a patient safety incident & explore contributory factors. We introduce methods such as observation & interview and consider how to generate areas for improvement and safety actions. Includes: A one-day healthcare focused course. Facilitated by experienced, doctors, nurses & educators. Small group work. Selected course materials. Membership of the Being Human in Healthcare Network. Register
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- Patient safety strategy
- Human factors
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EventThis 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 risk and behaviour to improve patient safety. Key learning objectives: Evaluating risk Using mapping techniques Safety interventions Behaviour Assessing safety culture Register
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- Human factors
- System safety
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EventThis 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 safety. Key learning objectives: Understand what Human Factors are Learning from incidents Designing system-based solutions Preventing human error Blame and psychological safety Just culture Register
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- Human factors
- Organisational culture
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Event
Safety-II Practical Applications conference
Patient Safety Learning posted an event in Community Calendar
untilThe 2023 Safety-II Practical Applications Conference is an opportunity for shared learning to advance organisational safety maturity. Traditional methods for safety management, while important, are limiting and often reactive. Many safety professionals have focused on Safety-II as an expanded, more proactive approach that focuses on maximizing learning. The intent of this conference is to provide practical tools for implementation of Safety-II and other next generation strategies. Major themes: Maximising proactive learning opportunities. Developing effective management and cultural systems. Observing and managing high-risk and/or error-likely situations. Learning to shift narratives and distinctions to influence culture. Case studies from many organisations. Register- Posted
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- Organisational culture
- Organisational learning
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EventuntilWhat we’re getting wrong about the “Five rights of medication use” and other safety myths Despite decades of focus, medication errors, which result from weak medication systems and human factors, constitute the greatest proportion of total preventable harm. Yet across decades of efforts to improve medication safety, a disproportionate burden continues to be placed on human performance, while examination and focus on improving systems and the cultures in which humans work is often limited and reactive. In recognition of World Patient Safety Day, this free Institute for Healthcare Improvement (IHI) webinar examines how traditional approaches to medication safety continue to impede progress. Interprofessional faculty with expertise in systems thinking and human factors engineering will share insights on reorienting our thinking and approaches to medication safety. This webinar will provide fresh ideas for engaging a cross-disciplinary, systems perspective and harnessing team members in the improvement of systems to support medication safety. What you'll learn Review commonly held myths about humans that limit progress in medication safety, including the “Five Rights of Medication Use.” Discuss how human factors design and interventions support human performance and improvements in medication safety. Identify at least one idea for change that you can consider for improving medication safety in your organization. Register This webinar will take place at 12:00-13:00 ET (17:00-18:00 BST)
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- System safety
- Medication
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EventuntilAfter two years with virtual workshops due to the Covid-19 pandemic, we are pleased to announce that the fifth International Workshop on Safety-II in Practice will be organised on site in Edinburgh, Scotland on September 7-9, 2022. The Workshop is organised by FRAMsynt. The workshop will begin with an optional half-day tutorial on Safety-II in Practice in the afternoon of September 7 (1330-1730 BST), and continue with two days of meetings and discussions from September 8 (0830-1700 BST) to September 9 (0830-1500 BST). There will be a walking tour of Edinburgh old town (hosted by Steven Shorrock) and a dinner on the evening of September 8 for those who wish to join. Aim of the workshop The aim of the workshop is to share experiences from existing and/or planned applications of a Safety-II approach in various industries and practices. The workshop will give the participants an opportunity to present and discuss problems encountered and lessons learned – good as well as bad, practical as well as methodological. The workshop is a unique opportunity for safety professionals and researchers to interact with like-minded colleagues, to debate the strengths and weaknesses of a Safety-II approach, and to share ideas for further developments. The guiding principle for the workshop is “long discussions interrupted by short presentations”. In order to achieve this, the number of participants will be limited to 60 – first come, first served. Participation The workshop is open to everyone regardless of their level of experience with Safety-II. It will address the use of Safety-II in a variety of fields and for purposes ranging from investigations, performance analyses, organisational management and development, individual and organisational learning, and resilience. The workshop will provide a unique opportunity to: Discuss and exchange experiences on how a Safety-II approach can be used to analyse and manage complex socio-technical systems. Receive feedback on and support for your own Safety-II projects and ideas. Learn about the latest developments and application areas of Safety-II. Develop a perspective on the long-term potential of a Safety-II approach. Discussion topics, presentations and papers You can contribute actively to the workshop by submitting proposals for: Topics or themes for panel discussions (preferably with a presentation or introduction, but open suggestions of themes are also welcome). Presentations of ongoing or already completed work in industry and/or academia. Ideas that you would like to get a second opinion on. Questions or issues that you have been wondering about and would like to hear more about. The relevance of a Safety-II perspective for individual and organisational learning. The strategic management of Safety-II: how to introduce changes to routines and daily practice. For each type of proposal, please provide a short abstract (about 100 – 200 words, but even less if need be) with a summary of what you would like to present or discuss and how you want to be involved. All proposals will be reviewed and comments to the submitters will be provided. Please submit your proposed contribution to: contact@humanisticsystems.com Register
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- Safety II
- System safety
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Event
Designing complex system
Patient Safety Learning posted an event in Community Calendar
untilThis 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 -
Event
Creating safe systems
Patient Safety Learning 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 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 objectives: evaluating risk using mapping techniques safety interventions behaviour assessing safety culture The course is facilitated by Perbinder Grewal, a General & Vascular Surgeon, Human Factors & Patient Safety Trainer, and Emotional Intelligence Practitioner; leads on medical education both locally and nationally; Member of the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh; formerly lead for e-learning for healthcare for the Royal College of Surgeons of England; experienced trainer and coach who uses new insights to develop patient safety, staff engagement and psychological safety; has Postgraduate Certificates in Leadership and Coaching. Register- Posted
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- System safety
- Behaviour
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EventThis 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 safety. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-based-solutions-patient-safety-masterclass or email aman@hc-uk.org.uk hub members receive a 20% discount code. Please email info@pslhub.org for a discount code.
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- System safety
- Human factors
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Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
- Behaviour
- Resources / Organisational management
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- Behaviour
- Resources / Organisational management
- Communication problems
- Decision making
- Organisation / service factors
- System safety
- User centred design
- Culture of fear
- Duty of Candour
- Just Culture
- Leadership
- Organisational culture
- Organisational development
- Organisational learning
- Safety culture
- Transformation
- Speaking up
- Transparency
- Whistleblowing
- Change management
- Collaboration
- Hierarchy
- Staff support
- Benchmarking
- Clinical governance
- Accountability
Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views?- Posted
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- Behaviour
- Resources / Organisational management
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- Behaviour
- Resources / Organisational management
- Communication problems
- Decision making
- Organisation / service factors
- System safety
- User centred design
- Culture of fear
- Duty of Candour
- Just Culture
- Leadership
- Organisational culture
- Organisational development
- Organisational learning
- Safety culture
- Transformation
- Speaking up
- Transparency
- Whistleblowing
- Change management
- Collaboration
- Hierarchy
- Staff support
- Benchmarking
- Clinical governance
- Accountability
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Community PostSee Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.
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- Patient death
- Patient harmed
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Content ArticleThis book, edited by Chartered Health Psychologist Holly Blake, demonstrates the breadth of research on work, health and wellbeing, during and beyond the COVID-19 pandemic, covering workforce impacts and workforce interventions in various countries and settings. Learning from this research will help to build global preparedness for future pandemics and foster resilience for responding in times of crisis and uncertainty.
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- Staff safety
- Mental health
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Content ArticleThis investigation aims to improve patient safety by supporting healthcare staff in a surgical setting to select and insert the appropriate type of implant (vascular graft) for haemodialysis treatment. The Healthcare and Safety Investigation Branch (HSIB) explored the factors that affect the ability of staff to safely select and insert vascular grafts for haemodialysis treatment. The national investigation focused on: The identification of factors within the healthcare system as a whole that influence patient safety risks associated with the selection and insertion of vascular grafts in an operating theatre environment. Exploration, using a systems approach, of the design of labelling and packaging used for the different types of vascular grafts for patients on haemodialysis treatment. Exploration of the impact on operating theatre teams of staff redeployment and repurposing of working environments in response to the COVID-19 pandemic.
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- Investigation
- Medical device
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