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Found 147 results
  1. Content Article
    In this article they use this case to highlight the importance of analysing errors using a systems approach. James Reasons 'Swiss cheese model of medical errors' is explained and put into context.
  2. Community Post
    Do any areas of healthcare capture ALL near misses and act on them? What systems do you use?
  3. Content Article
    The review will summarise the literature relating to contributory factors to patient safety incidents in primary care. The findings from this review will provide an evidence-based contributory factors framework for use in the primary care setting. It will increase understanding of factors that contribute to patient safety incidents and ultimately improve quality of healthcare.
  4. Content Article
    The tools will help you examine how tests are managed in your office, from the moment tests are ordered until the patient is notified of the test results and the appropriate follow up is determined.
  5. News Article
    China has introduced a new law with the aim of preventing violence against medical workers. The announcement comes days after a female doctor was stabbed to death at a Beijing hospital. The law bans any organisation or individual from threatening or harming the personal safety or dignity of medical workers, according to state media. It will take effect on 1 June next year. Under the new law, those "disturbing the medical environment, or harming medical workers' safety and dignity" will be given administrative punishments such as detention or a fine. It will also punish people found illegally obtaining, using or disclosing people's private healthcare information. Read full story Source: BBC News, 29 December 2019
  6. Content Article
    About the authors Robert W. Proctor is a distinguished professor of Psychological Sciences at Purdue University. He is a fellow of the American Psychological Association, Association for Psychological Science, and the Human Factors and Ergonomics Society, and recipient of the Franklin V. Taylor Award for Outstanding Contributions in the Field of Applied Experimental/Engineering Psychology from Division 21 of the American Psychological Association in 2013. He is co-author of Stimulus-Response Compatibility: Data, Theory and Application, Skill Acquisition & Training, and co-editor of Handbook of Human Factors in Web Design. Trisha Van Zandt is a professor of Psychology at The Ohio State University. She is a member of the Society for Mathematical Psychology, of which she was President in 2006-2007, and the American Statistical Association. She has received multiple research grants from the National Science Foundation and the Presidential Early Career Award for Scientists and Engineers in 1997. She is co-author of review chapters "Designs for and Analyses of Response Time Experiments" in the Oxford Handbook of Quantitative Methods and "Mathematical Psychology" in the APA Handbook of Research Methods in Psychology.
  7. Content Article
    This article from Nursing Open, published here by Wiley Online Library, aims to investigate whether nurse reported teamwork with physicians was associated with patient perceived consistency in staff‐to‐patient communication.
  8. Content Article
    Wrong tooth extraction has been clearly designated as a 'never event' since April 2015. However, in 2016/17, wrong tooth extraction topped the charts as being the most frequently occurring never event based on NHS England’s data. What can we do to mitigate these incidents? Based on both practical experience and research evidence, BAOS advises that the main methods for mitigation of errors are: learning from mistakes – including investigation and root cause analysis engaging the clinical team when developing 'correct site surgery' policies utilising the LocSSIPs template and guidelines from NHS England/RCS England developing a correct site surgery checklist that is appropriate for your clinical environment providing training for staff on the use of the checklist ensuring that the checklist is being used correctly through active audits of the processes involved supporting the clinical team throughout the process and not taking punitive action when incidents do occur.
  9. Content Article
    The Royal College of Emergency Medicine outline the actions required and call on health service leaders to encourage whole system ownership of ED performance, with every part of the hospital understanding the importance. The guide and accompanying video describes what systems should do appropriate to the performance ‘zones’ EDs find themselves in: Green (4 hour performance >95%), Amber (85-95%), or Red (<85%).
  10. Content Article
    In this article, Dan looks back at the Donabedian Model, a framework for measuring healthcare quality, and suggests why this might be an over simplification and why we must also look at human factors when we think about patient safety. We are humans and we can, do and will make mistakes, so we have a personal responsibility to acknowledge and address this as a contributing factor for patient safety incidents and harm. How do we begin to address our individual responsibilities? How can each of us reduce the personal risks we pose for our patients? How do we begin to address the moral imperative to recognise and then overcome any professional complacency that may interfere with our performance? Dan believes by enhancing human performance within healthcare settings this will serve as the ultimate key to improving quality and safety. Recognition by clinicians of their own tendencies toward complacency and their own vulnerabilities toward making mistakes is to encompass a mandate for personal professional commitment and improvement. If patients are harmed on the frontlines in healthcare settings, then it is on the frontlines that many of the solutions can be found and safety improvements nurtured. First recognising, and then modulating, the human factors liabilities that exist on the frontlines and overcoming the challenges of professional complacency will be necessary steppingstones towards sustained improvements in providing patient safe care. Clinicians, managers and leaders need to work collaboratively to understand and overcome the challenges that human factors pose when addressing individual performance.
  11. News Article
    There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the years. Some patient safety progress has been made, but not enough when the history of NHS policy making in the area is analysed. Lessons going unlearnt from previous patient safety event crises is also an acute problem. Patient safety events seem to repeat themselves with the same attendant issues. Read full story Source: Harvard Law, 17 February 2020
  12. Content Article
    The use of artificial intelligence (AI) in patient care can offer significant benefits. However, there is a lack of independent evaluation considering AI in use. This paper from Sujan et al., published in BMJ Health & Care Informatics, argues that consideration should be given to how AI will be incorporated into clinical processes and services. Human factors challenges that are likely to arise at this level include cognitive aspects (automation bias and human performance), handover and communication between clinicians and AI systems, situation awareness and the impact on the interaction with patients. Human factors research should accompany the development of AI from the outset.
  13. Content Article
    This video gives a summary of the PRAISe project - a QI project about antibiotic stewardship, based on Learning from Excellence philosophy. Funded by the Health Foundation.
  14. Content Article
    Presented by Sidney Dekker, Safety Differently: The Movie tells the stories of three organisations that had the courage to devolve, de-clutter, and decentralise their safety bureaucracy. It is a story of hope; of rediscovering ways to trust and empower people and of reinvigorating the humanity and dignity of actual work.
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