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Showing results for tags 'System safety'.
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Content ArticleIn 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.
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Content ArticleTim 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.
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Content Article
The Cynefin Framework
Patient_Safety_Learning posted an article in Organisational
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.- Posted
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Content ArticleProfessor 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.
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- Organisational culture
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Content ArticleWeaknesses 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.
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Content ArticleThis 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.
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Content ArticleWhat 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.
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Content ArticleIn 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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- Patient safety strategy
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Content ArticleThis study, published in the Journal of Patient Safety, tells how Mackenzie Health responded to low safety culture scores by implementing a zero-harm strategy.
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Content ArticleIn this article, Roger Kline, Research Fellow at Middlesex University, explains what caused the sinking of the Herald of Free Enterprise ferry. The sinking of the Herald of Free Enterprise on March 6 1987 with the loss of 198 lives was an accident waiting to happen, highlighting the devastating consequences of abandoning safe working practices in the name of financial savings. Human factors science learned from the Herald disaster is widely applied in sectors as diverse as nuclear power stations and healthcare.
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- Human factors
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Content ArticleThis 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. Tracey talks to us about how her love of applying psychology led to her role in patient safety, the importance of putting users at the centre of developing the Patient Safety Incident Response Framework (PSIRF), and what we can learn from magicians about patient safety.
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Content ArticleThis editorial by Barbara Fain, Chief Executive of the Betsy Lehman Center in Massachusetts, highlights the need to focus on system safety and moving away from a culture of individual blame, in order to improve patient safety. Referring to the case of nurse RaDonda Vaught who was convicted of negligent homicide for a medication error at a Tennessee hospital, Barbara looks at research that demonstrates that people generally believe the best way to reduce the likelihood of medical errors is by choosing the right doctor, and argues that this cultural belief played into Vaught's conviction. She highlights the need to use evidence-based strategies to communicate with healthcare professionals and the public about the wider picture of patient safety and systems thinking.
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Content ArticleThis is a summary of a presentation given by NHS England's Lauren Mosley and Tracey Herlihey to discuss the Patient Safety Incident Response Framework (PSIRF) to the law firm Browne Jacobsen. The session covered key elements of PSIRF, what it means for coroners, litigation and trusts. There was also feedback from an early adopter trust,
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Content ArticleHuman factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system. This article explores how HFE can be used to improve patient safety, in particular using the Systems Engineering Initiative for Patient Safety (SEIPS) model, which depicts key characteristics and interactions between three core components: work system process outcomes
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Content ArticleThis blog is part of a series in which Steven Shorrock, an interdisciplinary humanistic, systems and design practitioner, outlines seven ‘archetypes of human work’. This blog looks specifically at 'The Messy Reality' archetype, which is characterised by adjustments, adaptations, variations, trade-offs, compromises and workarounds that are hard to prescribe and hard to identify, but that can become accepted and unremarkable for insiders. Steven examines what 'The Messy Reality' is, why it exists and highlights some examples from the aviation and healthcare industries.
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Content ArticleThis webinar hosted by the National Orthopaedic Alliance (NOA) gives a brief overview of human factors and ergonomics, its relevance and role in improving patient safety, how it has been embedded in one organisation and the impact it has had. Fran Ives, Human Factors Specialist and part of the Human Factors team at the Robert Jones and Agnes Hunt Hospital (RJAH) speaks about her experience of applying Human Factors both within a large NHS Trust and an Academic Health Science Network, including the successes and challenges of setting up and developing a service, and what difference such a service can make.
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Content ArticleRadar Healthcare has published its 'Incident Reporting in Secondary Care' whitepaper – an in-depth analysis of reporting within secondary care and its effects on patient safety. It has taken a look into the current state of incident reporting: the good work being done, the concerns across the sector, and how we can all aim to improve the situation. The report was conducted using a panel provided by SERMO from its database of UK Nurses and includes the views from 100 nursing staff members working in hospital wards across the UK. Those surveyed work with hospital in-patients daily and are responsible for reporting safety and regulatory incidents involving patients to senior colleagues.
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- Patient safety incident
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Content ArticlePatient safety remains a global challenge for society today; in high income countries, it is estimated that one patient in ten is subject to adverse events while receiving hospital care. This article by Laís Junqueira, Quality, Patient Safety and Innovation Manager at Elsevier, in The Journal of mHealth looks at how enabling safer healthcare decision-making could reduce the burden of avoidable harm. Junqueira highlights the need to recognise that non-analytic and implicit decisions occur in healthcare systems, and that these have an impact on patient safety. He argues that as healthcare systems evolve, there must be an increased focus on the importance of an environment that fosters safe decision-making.
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- Decision making
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Content ArticleNaming, shaming, and blaming the “poor performers” or “outliers” won’t help the staff working there, or the patients using their services—but it makes politicians appear to be taking tough action, holding the NHS to account for its use of public money, and acting as patients’ champions, writes David Oliver in this BMJ article.
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- Organisation / service factors
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Content ArticlePublished on 19 October 2022, the report of the investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. The investigation found that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed. In this article, Patient Safety Learning analyses the findings of this report from a broad patient safety perspective, focusing on five key themes that are consistent with many other serious patient safety inquiries and reports in recent years. It sets these in their wider context and highlights the need for a fundamental transformation in our approach to patient safety if similar scandals are to be prevented in the future.
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Content ArticleThis 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. Tracey talks to us about the role of NHS Supply Chain in ensuring the products procured through the NHS Supply are of high quality and are safe for healthcare organisations to use. She also highlights the vital importance of complaints and the need for staff who don’t work in direct care delivery to recognise their role in patient safety.