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Showing results for tags 'System safety'.
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Content ArticleThe pandemic has emphasised the high risk of avoidable harm to patients, health workers, and the general public, and has identified a range of safety gaps across all core components of health systems at all levels. The World Health Organization (WHO)'s rapid review ‘Implications of the COVID-19 pandemic for patient safety’ explores impacts that the COVID-19 pandemic did have on patient safety in terms of risks and avoidable harm, specifically in terms of diagnostic, treatment and care management related issues as well as highlights the main patterns of these implications within the broader health system context.
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Content ArticleProfessor Peter Brennan is a NHS Consultant Surgeon in Portsmouth, specialising in head and neck cancer. In this episode of the Human Factor Podcast, Peter discusses how he is driving Human Factors approaches from his perspective. To date, Peter has published over 700 publications including more than 80 on Human Factors and patient safety. His HF work has changed the delivery of postgraduate surgery exam delivery in the UK and abroad. Watch all the Human Factors Podcast episodes here.
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Content ArticleProfessor Ron McLeod's presentation on the Chartered Institute of Ergonomics & Human Factors (CIEHF) White Paper on Human Factors in highly automated systems.
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- Human factors
- High reliability organisations
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Content ArticleEach year, 7,000 to 9,000 people die as a result of a medication errors in the US, and the total cost of looking after patients with medication-associated errors exceeds $40 billion. Alongside this financial cost, adverse events caused by medication errors also cause patients significant psychological and physical pain and suffering. The article aims to: identify the most common medication errors. review some of the critical points at which medication errors are most likely to occur. outline strategies to prevent medication errors occurring. summarise multidisciplinary team strategies for decreasing medication errors.
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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. Jordan talks to us about his journey from drama school to patient safety, how the new Patient Safety Incident Response Framework (PSIRF) will change the way the NHS looks at safety, and how his love of driving makes him think differently about his role. A transcript of the interview is also available below.
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Content ArticleIn this blog, Chris Day, Director of Engagement at the Care Quality Commission (CQC) sets out more detail on the CQC’s role in the assessment of Integrated Care Systems (ICSs). He highlights the importance of developing regulation that earns the trust of both people using services and those working in them. He outlines how the CQC will use its new responsibilities under the Health and Care Act 2022 to assess the extent to which each ICS understands the needs of its local population and whether it is working effectively in collaboration, with valued input from all health and care partners.
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- Regulatory issue
- Patient engagement
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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
- Safety culture
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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 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 ArticleHealthcare can be risky. Adverse events carry a high cost – both human and financial – for health systems around the world. So in an effort to improve safety, many health systems have looked to learn from high-risk industries. The aviation and nuclear industries, for example, have excellent safety records despite operating in hazardous conditions. And increasingly, the tools and procedures these industries use to identify hazards are being adopted in healthcare. One prominent example involves the Hierarchy of Risk Controls (HoC) approach, which works by ranking the methods of controlling risks based on their expected effectiveness. According to HoC, the risks at the top are presumed to be more effective than those at the bottom. The ones at the top typically rely less on human behaviour: for example, a new piece of technology is considered to be a stronger risk control than training staff. This article looks more deeply at the (HoC) 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 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.
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How can Parliament make health and care safer for all? (4 November 2022)
Mark Hughes posted an article in Others
In this blog for the cross-party think tank Policy Connect, the Professional Standards Authority for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care outlined in its report Safer care for all - solutions from professional regulation and beyond. It describes gaps in the wider framework to protect the public highlighted in this report and considers where Parliament and the Government have an opportunity to act to support safer care for all. Related reading Patient Safety Learning: Joining up a fragmented landscape: Reflections on the PSA report ‘Safer care for all’ (12 September 2022) Working together to achieve safer care for all: a blog by Alan Clamp (12 September 2022)- Posted
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Content ArticleThis article in the BMJ highlights a number of recent articles that reflect on the realities facing the health service after the first brutal years of the Covid-19 pandemic. It summarises and links to articles in the BMJ about the elective care backlog, A&E waiting times, remote appointments, Government pressures that stop senior clinicians speaking out about pressures, and the need for credible policy solutions. It also highlights an article outlining how Brexit and the Northern Ireland Protocol have resulted in the UK being denied access to European research funding and meetings.
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- System safety
- Workforce management
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Content ArticleSteven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. In this blog, he reflects on what he has learned from 25 years as a human factors expert, highlighting that human factors is essentially about improving work, via design.
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- Human factors
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Content ArticleClinical trials are the foundation of modern medicine, but regulators, doctors and patients often do not get to see the full picture about how safe and effective drugs and treatments are. The results of around half of all clinical trials remain hidden and there are international efforts to resolve this issue; even government agencies often lack access to the information they need to decide whether treatments are safe and effective. The paper analyses six case studies in which lack of transparency in medical research has directly harmed patients, taxpayers and/or investors. It illustrates how these harms could have been avoided through three simple solutions promoted by the AllTrials campaign: trial registration, results posting, and full disclosure of trial reports.
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- Medication
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Content Article
Blog - Is human error a crime? (2 November 2022)
Patient-Safety-Learning posted an article in Legal matters
Martin Anderson, author of the Human Factors 101 blog, looks at the case of US nurse RaDonda Vaught, who was found guilty of criminally negligent homicide and abuse of an impaired adult following a medication error that led to a patient death in 2017. He provides a timeline of the events that occurred in the run up to the criminal trial and highlights concerns that the case will set a precedent in bringing criminal charges against nurses when there is no intent to harm a patient. He then looks at the system factors that may have contributed to the medication error, asking a number of questions about the circumstances under which Vaught made the error. The blog goes on to outline the serious impact the case could have on healthcare professionals' willingness to report errors, take on complex cases and use innovative treatments—it may even put people off taking on a career in the healthcare sector in the first place.- Posted
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- Human error
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Content ArticleThe Covid-19 pandemic has, in many ways, been healthcare’s finest hour. Clinicians performed miracles as they battled to understand a new disease, learning as they went along the techniques and approaches that gave patients the best chance of survival. But, for all this quiet heroism, the crisis also turned a harsh spotlight on the deficiencies of health systems, writes Sarah Neville in this Financial Times article.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) third annual conference took place on 21 September 2022. Presentations and videos from the day are now available to view and download below. Although it tied in with the World Health Organization’s World Patient Safety Day theme of medication safety, our speakers also covered: how we can drive system level change practical sessions based on our HSIB investigation education courses maternity safety insights themed around inclusivity of care opportunities for sharing and learning from Norway’s healthcare safety investigation body, UKOM.
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Content ArticleIf you want to find out what the new Patient Safety Incident Response Framework is all about, and how it will support the NHS to learn and improve, this video provides a helpful introduction.
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- PSIRF
- Investigation
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Content ArticleIn this blog, The Patients Association's Chief Executive Rachel Power argues that the findings of the independent investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust demonstrate the repeated failure of maternity services in England to offer safe and compassionate care to families. She outlines the key findings of the report, including catastrophic failures in the organisation's culture, team working and professionalism, and failure to listen to patients. She highlights that the lack of honesty shown by the Trust to individuals and families harmed by the hospitals' failures is shocking, and compounded the suffering felt by each family.
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- Maternity
- Investigation
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Content ArticleIn basic terms, a safety management system (SMS) is a formal arrangement for managing, assuring, and improving safety. An SMS is not a single document, it is a framework for managing all risks that arise from running a transport system. It defines roles and responsibilities, sets arrangements for safety mechanisms, involves workers in the process, and ensures continuous improvement. The Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS) introduced the requirement for and content of an SMS. The regulations require most railway operators to maintain an SMS, and hold a safety certificate or authorisation indicating that the SMS has been accepted by the Office of Rail and Road.
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Content Article
Skybrary: Safety Management System in aviation
Patient Safety Learning posted an article in Organisational
The objective of a Safety Management System is to provide a structured management approach to control safety risks in operations. Effective safety management must take into account the organisation’s specific structures and processes related to safety of operations.- Posted
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- Aviation
- Safety management
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