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Found 511 results
  1. Content Article
    This paper aims to highlight how to reduce medication errors through the implementation of human factors science to the design features of medication containers. Despite efforts to employ automation for increased safety and decreased workload, medication administration in hospital wards is still heavily dependent on human operators (pharmacists, nurses, physicians, etc.). Improving this multi-step process requires its being studied and designed as an interface in a complex socio-technical system. Human factors engineering, also known as ergonomics, involves designing socio-technical systems to improve overall system performance, and reduces the risk of system, and in particular, operator, failures. The incorporation of human factors principles into the design of the work environment and tools that are in use during medication administration could improve this process. During periods of high workload, the cognitive effort necessary to work through a very demanding process may overwhelm even expert operators. In such conditions, the entire system should facilitate the human operator’s high level of performance. Regarding medications, clinicians should be provided with as many perceptual cues as possible to facilitate medication identification. Neglecting the shape of the container as one of the features that differentiates between classes of medications is a lost opportunity to use a helpful characteristic, and medication administration failures that happen in the absence of such intentional design arise from “designer error” rather than “user error”. Guidelines that define a container’s shape for each class of medication would compel pharmaceutical manufacturers to be compatible and would eliminate the confusion that arises when a hospital changes the supplier of a given medication.
  2. Content Article
    Fatigue is a workplace hazard that affects the health and safety of patients, health care providers and the community. This blog from health tech company Cerner looks at the importance of managing fatigue in healthcare staff. The author suggests a three-step approach to lessen fatigue: Shift the culture of safety to include recognising and dealing with fatigue. Operationalise fatigue reduction measures within the organisation. Promote fatigue self-management through preventative strategies.
  3. Content Article
    Hours of work and other conditions of service are matters for agreement between employers and staff, but it is vital that working patterns are designed to reduce risks from fatigue as much as is practical. This resource from the Office of Rail and Road outlines why the rail industry needs to take staff fatigue seriously, and provides links to key guidance.
  4. Content Article
    Healthcare relies on high levels of human performance; however, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. This narrative review in the journal Anaesthesia aims to describe what is known about human factors in anaesthesia to date.
  5. Content Article
    Fatigue refers to the issues that arise from excessive working time or poorly designed shift patterns. It is generally considered to be a decline in mental and/or physical performance that results from prolonged exertion, sleep loss and/or disruption of the internal clock. Fatigue results in slower reactions, reduced ability to process information, memory lapses, absent-mindedness, decreased awareness, lack of attention and underestimation of risk. It can lead to errors and accidents, ill-health and injury, and reduced productivity and is often a root cause of major accidents. This guidance from the Health and Safety Executive (HSE) outlines key information about fatigue and signposts to further resources about managing fatigue at work.
  6. Content Article
    In this blog, published by What's The Pont, the author provides a summary of the The Swiss Cheese Model of Accident Causation, developed by Professor James T. Reason, and looks at what it means for learning from failure. Related reading: The Swiss cheese respiratory virus pandemic defence Reverse Swiss Cheese – Driving safety culture from the blunt end (24 June 2022) Good and bad reasons: The Swiss cheese model and its critics (June 2020)
  7. Content Article
    ‘Human factors’ is the science of improving performance by understanding individual or team behaviour and cognitive biases. This can allow a redesign of clinical systems and environments to improve patient safety. This course aims to help healthcare professionals understand human factors in complex healthcare setting and can be delivered as a full day, half day or a conference talk. It was developed by Professor Robert Galloway, Emergency Medicine Consultant at University Hospitals Sussex NHS Trust. The course covers: the principles of ‘human factors’–why errors occur. human cognitive biases (in memory, reasoning, decision-making). practical skills and tools to improve individual/team performance and patient safety. You can email Rob Galloway for more information on booking this course.
  8. Content Article
    Eurocontrol’s HindSight magazine is a magazine on human and organisational factors in operations, in air traffic management and beyond. This issue is on the theme of Handling Surprises: Tales of the Unexpected. You will find a diverse selection of articles from frontline staff, senior managers, and specialists in operations, human factors, safety, and resilience engineering in the context of aviation, healthcare, maritime and web operations. The articles reflect surprise handling by individuals, teams and organisations from the perspectives of personal experience, theory, research and training. 
  9. Content Article
    It is difficult to monitor compliance to surgical checklists, which is associated with improved patient outcomes. This research study in The Annals of Surgery reported for the first time on the use of the Operating Room Black Box (ORBB) to track checklist compliance, engagement, and quality. The authors took a retrospective review of prospectively collected ORBB data and measures of checklist compliance, engagement and quality were assessed. ORBB provides the unprecedented ability to assess not only compliance with surgical safety checklists but also engagement and quality. This technology allows the assessment of compliance in near real time and to accurately address safety threats that may arise from noncompliance.
  10. Content Article
    Safety-II is moving beyond the conceptual, with practical applications emerging from the fog of models and theory. But critics still point to a lack of evidence and limited real-world proof that the promise is justified. This blog reports on a webinar by Mark Sujan and Simon Gill that looked at how to implement Safety-II thinking in real world settings. The blog outlines different elements of the webinar including: a case study of anticipatory practice being used to reduce serious harm from falls in an emergency department a discussion on how to move towards a non-hierarchical clinical leadership challenges to adopting Safety-II principles evaluation of Safety-II: how do you measure a non-event?
  11. Event
    This 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
  12. Content Article
    In this blog, Jonathan Back, Intelligence Analyst at the Healthcare Safety Investigation Branch (HSIB), looks at the opportunities the healthcare system has to adopt proactive risk management to improve patient safety. He highlights that understanding the value of different perspectives may provide new opportunities for improvement if applied across the health and care system. He also outlines the role of the new integrated care boards (ICBs) in achieving this whole-system approach, which should include a clinical governance perspective, organisational and local system perspective and societal perspective.
  13. Content Article
    In a blog for National Voices, the leading coalition of health and social care charities in England, Patient Safety Learning’s Chief Executive Helen Hughes discusses an independent report written by risk expert Tim Edwards that highlights serious and widespread safety concerns around the misdiagnosis of pulmonary embolism.
  14. Content Article
    This guidance on implementing human factors in anaesthesia has been produced by the Difficult Airway Society and the Association of Anaesthetists. Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker wellbeing; implementing human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a ‘hierarchy of controls’ model and classified into design, barriers, mitigations and education and training strategies.
  15. Content Article
    In this article, published by BMJ Opinion, author David Raven says:  "Emergency care staff have been working under the shadow of a slow moving catastrophe for years". David, emergency medicine consultant and divisional director of urgent care, provides several examples of data and high level concerns raised that attempted to forewarn of these dangers. He argues that blaming Covid and high levels of flu for the pressures provides a false narrative to the reality and that the relentless hard work of staff is not enough to compensate for the challenges they face in what he says is a dysfunctional system.  
  16. Content Article
    This BMJ Opinion piece is written by Chris Ham (in a personal capacity)who was chief executive of The King’s Fund from 2010 to 2018. Chris talks about the recent funding announcement to support hospital discharges in order to free up bed space. He highlights a number of key considerations including: the impact on patient involvement in their discharge decisions staff shortages in care homes bed capacity in care homes. Chris questions whether these decisions are 'symbolic policy making' or whether they will actually make a difference to patients.
  17. Content Article
    In December 2022, the All Party Parliamentary (APPG) for Whistleblowing heard evidence on the state of the NHS following the recent report on the avoidable deaths and life changing injuries caused to mothers and babies at the East Kent Trust. The culture at this hospital was described as one where “everyone knew the problems” and where whistleblowers were “thrown to the lions”. A culture attributed to 45 of the 65 baby deaths reviewed.  This blog first appeared on the Whistleblowers UK website in December 2022.
  18. Content Article
    Tim Edwards is a risk management expert and son of Jenny, who passed away in February 2022 from pulmonary embolism (PE), following a misdiagnosis. Frustrated by the quality of the initial investigation that followed her death and the lack of assurance that learning would take place, Tim conducted an independent review: Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns. Drawing on existing data, freedom of information requests and Jenny’s case, the report raises significant patient safety concerns relating to PE care across England and Wales. Tim calculated that from April 2021 to March 2022, there was a minimum of 400 excess deaths due to pulmonary embolism misdiagnosis. In this opinion piece, Tim draws on his research to highlight the key patient safety issues, and to encourage further dialogue around the topic. 
  19. Content Article
    Cynefin, pronounced kuh-nev-in, is a Welsh word that signifies the multiple, intertwined factors in our environment and our experience that influence us (how we think, interpret and act) in ways we can never fully understand.  The Cynefin Framework was developed to help leaders understand their challenges and to make decisions in context. It has been applied to many different environments including healthcare and safety. To read more about the framework and to watch a 12-minute introductory film, follow the link below to the Cynefin Co website.
  20. Content Article
    Professor Mary Dixon-Woods looks at improving the quality and safety of care in hospitals, and suggests that we need to take a three-pronged approach: ensuring we are collecting the right data and interpreting it intelligently, looking at the systems we work in and finally how culture and behaviour impact on quality of care.
  21. Content Article
    Weaknesses resulting from a patchwork of patient safety processes developed by individual healthcare organisations over the past quarter-century, exposed by the Covid-19 pandemic, can be remedied through both local systems design support and widespread best practices uniformity.
  22. Content Article
    This article, published in The international journal for quality in healthcare, looks at the Hierarchy of Risk Controls approach to explore its usefulness and effectiveness in healthcare. To investigate this issue, a team of social scientists examined the risk controls introduced by four hospital teams in England and Scotland after they had identified hazards in their systems.
  23. Content Article
    What is resilience? What is resilience engineering? This 25-minute talk, published by devopsdays, will ground your understanding of those terms using the compelling example of bone.  Dr. Richard Cook is a Principal with Adaptive Capacity Labs and Research Scientist in the Department of Integrated Systems Engineering at The Ohio State University (OSU) in Columbus, Ohio.
  24. Content Article
    Resilience Engineering refers to building complex systems that are resilient to change and disruption. In this blog, the author reflects on his own reading around the topic and how we might apply resilience engineering.
  25. Content Article
    In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
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