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Showing results for tags 'System safety'.
Found 515 results
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Content ArticleThis worksheet produced by NHS Education for Scotland is designed to be used by healthcare teams as a prompt to highlight the various system-wide factors that contribute to an issue. It aims to help teams understand how these factors relate and interact to produce different outcomes.
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Content ArticleThese slides provide the outline of a tutorial about the Causal Analysis using System Theory (CAST) and System-Theoretic Accident Model and Processes (STAMP) approaches to accident analysis, delivered at the Second STAMP Conference in 2013. The presentation slides cover: Model and method: Why STAMP and CAST? Why do accident analysis? Goals for an accident analysis technique Overcoming hindsight bias CAST worked example of emergency plane landing
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Content ArticleModels and methods of work system design need to be developed and implemented to advance research in and design for patient safety. In this paper, Carayon et al. describe how the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety, which provides a framework for understanding the structures, processes and outcomes in health care and their relationships, can be used toward these ends. An application of the SEIPS model in one particular care setting (outpatient surgery) is presented and other practical and research applications of the model are described.
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Content ArticleOver the last 20 years, the Royal College of Art has been a fierce proponent of the role of design to improve and save lives, leading the debate on the efficacy of design thinking when applied to real societal needs. Nowhere is this better exemplified than by its impact on healthcare and patient safety. With increasing pressure on the national healthcare system, public services and provisions have to meet ever more stringent financial, resource and efficiency objectives. The Royal College of Art has demonstrated how systems-led thinking and a design approach to understanding the user’s needs can effectively reduce infection and medical error, and improve treatment spaces and patient communication.
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Content ArticleRecording for the Session on Patient Safety held on 31 October as a part of the Global Indian Physician COVID-19 Collaborative.
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Content Article
Continuity of Carer (CoC) is a way of working within maternity services. It aims to provide a consistency in the care given to people before, during and after birth, limiting the number of clinicians involved in their journey. Evidence shows this approach improves safety, leads to better outcomes and is preferred by patients. In this blog, Samantha Phillis, Community Midwife, uses powerful examples to illustrate how the CoC model has helped her look after her patients.- Posted
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Content ArticleRobbie Powell, 10, from Ystradgynlais, Powys, died at Swansea's Morriston Hospital, of Addison's disease in 1990. Four months earlier Addison's disease had been suspected by paediatricians at this hospital, when an ACTH test was ordered but was not carried out. Although Robbie's GPs were informed of the suspicion of Addison's disease, the need for the ACTH test and that Robbie should be immediately admitted back to hospital, if he became unwell, this crucial and lifesaving information was not communicated to Robbie's parents. At the time of Robbie's death, the Swansea Coroner refused the Powells' request for an inquest claiming that the child had died of natural causes. However, the Powells secured a 'Fiat' [Court Order] from the Attorney General in 2000 and an inquest took place in 2004, fourteen years after Robbie died. The verdict was 'natural causes contributed by neglect' confirming that an inquest should have taken place in 1990. Since Robbie's death, his father Will Powell, has mounted a long campaign to get a public inquiry into Robbie's case.
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Content ArticleIt's important to think about how we are safe on the front line, doing the work day in and day out. How do our policies, processes and practices across an entire organisation impact the safety of our work? Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. He currently specialises as a human factors and safety specialist in air traffic control in Europe, but has worked across most safety critical sectors. In this podcast, from the East of England Ambulance Service (EEAST) General Broadcast, Steven talks about how policies can interfere with each other, how hierarchy impacts performance and reflects on incidents.
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Content ArticleThis resource from the Royal College of Midwives, contains practical information and contains interactive exercises for midwives to use on their own or as part of a group, to support implementation conversations relating to continuity of carer.
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Content ArticleHeralded as an easy fix for health services under pressure, data technology is marching ahead unchecked. In this article for the BMJ, Poppy Noor asks whether there a risk it could compound inequalities.
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Content ArticleIn this blog, Steven Shorrock reflects on why are we so resistant to change.
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Content ArticleThe latest figures from NHS Digital show the number of hospital episodes in England with a primary diagnosis of anaphylaxis increased from 5,497 in 2018-19 to 5,517 in 2019-20. Previous figures have shown the number of cases of children hospitalised with severe allergic reactions in England has increased by 72 per cent over the last six years. Overall, including adults, there has been a 34 per cent rise in admissions over the same period. Figures from 2019 reveal wide regional differences among children admitted to hospital with anaphylaxis. The health region with the highest increase is London where the number of cases has risen by 167% from 180 in 2013-14 to 480 in 2018-19. Among those ten and under, the increase is a staggering 200 per cent. Natasha Allergy Research Foundation (NARF) has renewed its call for the Government to appoint an ‘Allergy Tsar’ to co-ordinate and take steps to make sure people with allergies get the treatment and care they need. NARF first called for the appointment of an ‘Allergy Tsar’ earlier this year following the inquest of Shante Turay-Thomas, 18, who died in 2018 from anaphylaxis after eating hazelnut.
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Content ArticleComplexity science offers ways to change our collective mindset about healthcare systems, enabling us to improve performance that is otherwise stagnant, argues Jeffrey Braithwaite in this BMJ article. Jeffrey is a professor of health systems research and president elect of the International Society for Quality in Health Care.
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Content ArticleSince the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the number of cases of coronavirus disease (COVID-19) in the United States has exponentially increased. Identifying and monitoring individuals with COVID-19 and individuals who have been exposed to the disease is critical to prevent transmission. Traditional contact tracing mechanisms are not structured on the scale needed to address this pandemic. As businesses reopen, institutions and agencies not traditionally engaged in disease prevention are being tasked with ensuring public safety. Systems to support organisations facing these new challenges are critically needed. Most currently available symptom trackers use a direct-to-consumer approach and use personal identifiers, which raises privacy concerns. Kassaye et al. developed a monitoring and reporting system for COVID-19 to support institutions conducting monitoring activities without compromising privacy.
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Content ArticleThe NHS Patient Safety Strategy requires every Trust to have a Patient Safety Specialist: an evolving role with the purpose of ensuring that “systems thinking, human factors and just culture principles are embedded in all patient safety activity”. Patient safety is a big topic, and apart from a general sense of frustration that we don’t seem to be making any progress, there’s little agreement about what the problems are, let alone the solutions. Q member, John Tansley discusses his philosophy of patient safety through four key icons, and reflects on how this can inform and shape the evolving role of Patient Safety Specialists.
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Content ArticleThis article from Wood and Wiegmann, in the International Journal for Quality in Healthcare, discusses the action hierarchy, which is a tool for generating corrective actions to improve safety and focuses on those recommendations relying less on human factors and more on systems change. The authors propose a multifaceted definition of ‘systems change’ and a rubric for determining the extent to which a corrective action addresses ‘systems change’ (‘systems change hierarchy’).
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Content ArticleSafety governance refers to the approaches taken to minimise the risk for patient harm across an entity or system. It typically comprises steering and rule-making functions such as policies, regulations and standards. To date, governance has focused on the clinical level and the hospital setting, with limited oversight and control over safety in other parts of the health system. All 25 countries that responded to a 2019 OECD Survey of Patient Safety Governance have enacted legislation that aims to promote patient safety. These practices include external accreditation and inspections of safety processes and outcomes. Safety governance models are also moving away from punishment and shaming towards increased trust and openness. Learning from success as well as failures represents a paradigm shift in safety governance, an approach that has been increasingly adopted in OECD countries.
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Content ArticleEach quarter, the Patient Safety Movement Foundation hosts a free webinar to address a central patient safety topic. This virtual workshop session on the importance of human factors and systems safety focuses on re-designing work as opposed to re-designing the human who does the work. Incorporating a human factors and systems safety approach allows for the development and integration of knowledge, skills and attitudes that facilitate successful performance at the front lines of care. Healthcare leaders will learn how to apply human factors and systems safety concepts to understand true hazards in their organizations while fostering a culture of safety.
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Content ArticleHuman factors is a critical component of future aviation success in both military and civil aviation systems, especially where it concerns safety. This white paper from the Chartered Institute of Ergonomics and Human Factors contains the visions of 15 ‘thought leaders’, showing how they believe aviation evolution will unfold between now and 2050, and the critical role of human factors in ensuring system performance and safety. The thoughts in this paper can be applied to human factors in health and social care.
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Content ArticleThis study from the THIS Institute, published in BMJ Quality and Safety, seeks to characterise features of safe care in maternity units. Hospital-based maternity units in the study displayed features that reinforce each other to optimise safety. The paper describes these features in a plain language framework, the For Us – For Unit Safety framework. Preventable harm in maternity care has devastating consequences for families, and the associated negligence claims create huge costs for the NHS. Reducing harm in maternity care is a major priority to protect families and NHS sustainability. Much work to date has focused on identifying what goes wrong in maternity care. This study takes a fresh, positive perspective and shares learning about what good looks like for safety in maternity units. The result is the For Us framework, which identifies the behaviours and practices that appear to be features of safe care in hospital-based maternity units. The framework doesn’t tell staff working in maternity units what to do. Instead it aims to aid reflection and collective learning and to target improvement efforts. It is an evidence-based framework that aims to support staff working in maternity units to reflect on what good looks like in a safe maternity unit, to identify and agree on priorities for improvement, celebrate achievements, or to make a case for increasing investment to achieve safety.
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Content ArticleScienceDirect uses heuristic and machine-learning approaches to extract relevant information from their extensive collection of content. They compile this information on a topic-by-topic basis providing the reader both depth and breadth on a specific area of interest. This collection of research and data focuses on safety risk management.
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Content ArticleHealth IT (HIT) systems are increasingly becoming a core infrastructural technology in healthcare. However, failures of these systems, under certain conditions, can lead to patient harm and as such the safety case for HIT has to be explicitly made. This study from Habli et al., published in Safety Science, focuses on safety assurance practices of HIT in England and investigates how clinicians and engineers currently analyse, control and justify HIT safety risks. Two areas of strength were identified: establishment of a systematic approach to risk management and close engagement by clinicians; and two areas for improvement: greater depth and clarity in hazard analysis practices and greater organisational support for assuring safety. Overall, the dynamic characteristics of healthcare combined with insufficient funding have made it challenging to generate and explain the safety evidence to the required level of detail and rigour. Improvements in the form of practical HIT-specific safety guidelines and tools are needed. The lack of publicly available examples of credible HIT safety cases is a major deficit. The availability of these examples can help clarify the significance of the HIT risk analysis evidence and identify the necessary expertise and organisational commitments.
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Content ArticleTo celebrate the second annual World Patient Safety Day, the Canadian Patient Safety Institute (CPSI) are proud to premiere the documentary, Building a Safer System, showcasing the 17-year impact of the Canadian Patient Safety Institute. The film is followed by an expert panel discussion of the theme, Health Worker Safety – A Priority for Patient Safety.
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Content ArticleThis handbook provides tools for designing a structure for a management system, as well as the tools for documenting processes within it. The starting point is based on current safety research. The book is designed for medical professionals, managers, project members, politicians, public officials, and executives-all who work with patient safety matters. The content shows a new way to healthcare management, presenting an alternative approach together with concrete advice on how healthcare executives and practitioners can begin to think and act differently in order to provide safe healthcare.
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Content ArticleThe COVID-19 pandemic has exacerbated preexisting weaknesses in the global supply chain. Regional assessments by the Food and Drug Administration (FDA), European Medicines Agency (EMA), and independent consultants, have demonstrated various contributory causal factors requiring changes in policy, relationships, and incentives within the dynamic and developing networks. Human factors and ergonomics (HFE) is an approach that encourages sociotechnical systems thinking to optimize the performance of systems that involve human activity. The global supply chain can be considered such a system. However, it has neither been systematically examined from this perspective.
