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Found 74 results
  1. Community Post
    Hi all, I had a great meeting with @Neal Jones yesterday and in a wide ranging discussion we reflected on design and human factors. I recall some great work many years ago on the redesign of ambulances (that the NPSA contributed to) and wondered what happened to that initative and whether this had developed into designing new hospitals for patient safety. @Neal Jones recalled the DOME (designing out medical error) project http://www.domeproject.org.uk/index.html. This web site is dated 2010 and it seems to have been a three year funded project. Is this innovative approach still 'live?' Does an
  2. News Article
    NHS workers are at breaking point after months of upheaval and high pressure during the coronavirus outbreak with hospital leaders warning the health service is facing a “perfect storm” of workforce shortages and a second wave of COVID-19. In a survey of 140 NHS trust leaders almost all of them said they were worried about their staff suffering burnout ahead of winter. They also sounded the alarm over concerns there had not been enough investment into social care before this winter. NHS Providers, which carried out the survey ahead of its annual conference of hospital leaders, w
  3. News Article
    The health service lacks the beds, staffing and resources to cope with a serious outbreak of the coronavirus, The Independent has been told by senior doctors and nurses. NHS staff from across the country warned hospitals are already unable to cope, with patients being looked after in spill-over wards and waiting hours for a bed, with one doctor saying it was already a “one in, one out mentality” for intensive care. Other staff reported delays in lab tests, rationing of protective masks and equipment, and a lack of isolation areas for suspected coronavirus patients. Suggestions f
  4. News Article
    A hospital accused of bullying its staff is facing new claims that it failed to act on a leading doctor’s warning about a potentially fatal failure to monitor vulnerable patients, the Guardian newspaper can reveal. Dr Jonathan Boyle, the UK’s top vascular surgeon, had warned West Suffolk NHS trust that patients at risk of dying from burst aneurysms were not being safely monitored. An IT glitch meant that patients were not followed up to see how soon they would need potentially life-saving surgery. A doctor at the trust, however, says it initially repeatedly refused to take any action
  5. Content Article
    In this short film, Dr Peter-Marc Fortune discusses the role of human factors in the recognition, response and escalation of the deteriorating child.
  6. Content Article
    Working in healthcare has never been so demanding. The demand outweighs capacity in most services. There is a constant need for patients to be ‘flowing’ through the system. So much so, that there is little capacity for deviation from pathways that we have set up for certain groups of patients to enable their care to be ‘safer’. Our staffing templates and bed occupancy has no wiggle room for the ebbs and flows within the system at different times. Winter pressures now span from mid-summer to late spring – it just feels like the status quo. Having a busy day used to be every now and
  7. Content Article
    In two studies, researchers found that doctors with high levels of burnout had between 45% and 63% higher odds of making a major medical error in the following three months, compared with those who had low levels. To ensure well-being and motivation at work, and to minimise workplace stress, people have three core needs, and all three must be met. A - Autonomy/control – the need to have control over our work lives, and to act consistently with our work and life values. B - Belonging – the need to be connected to, cared for, and caring of others around us in the workplace and to
  8. 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.
  9. Content Article
    Key learning points Education and training of healthcare workers Equip the workforce with the fundamental knowledge and skills of human factors/ergonomics. Support, promote and embed the discipline in the practitioner’s professional training and development. Empower participation in human factor/ergonomic initiatives. Draw on existing expertise. Organisational commitment Comprehensive, resilient, proactive patient safety programme. Safety culture (not punitive to individual). Risk management system. Programme evaluation, meaningful and in
  10. Content Article
    What will I learn? This booklet offers brief guidance for people using the tool in practice. It includes: A brief overview of the tool How acuity and/or dependency are measured How to ensure that accurate data are collected What Nurse Sensitive Indicators will be allied to acuity and/or dependency measurement How to use nursing multipliers to support professional judgement What can be learned from the pilot sites and Frequently Asked Questions How to get help or support if needed.
  11. Content Article
    The Heinrich/Bird safety pyramid is presented in an article in Risk Engineering. It includes an infographic with Heinrich's Accident Triangle. This triangle suggests that the ratio between fatal accidents, accidents, injuries and minor incidents are similar across all industries. It highlights the importance of investigating the minor incidents to present fatal incidents. Challenge: In healthcare, are we investigating the wrong incidents?
  12. 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.
  13. Content Article
    Key points Communication between members of the surgical team is an integral component of the prevention of surgical fires. Open delivery of 100% oxygen should be avoided if at all possible for surgery above the xiphoid process. Surgeons usually control the ignition sources, such as electrosurgical units and lasers. Operating theatre nurses or practitioners usually control the fuel sources, such as alcohol-based preparations and surgical drapes. The use of an ignition source in close proximity of an oxidiser-enriched environment creates a high risk for surgical fir
  14. News Article
    An advanced nurse practitioner working in primary care services at Grimsby Hospital has called on the hospital senior leadership to ‘see for themselves how unsafe it is’. The nurse, who has penned a letter to bosses at Northern Lincolnshire and Goole NHS Foundation Trust says they are having “worst experience to date” in their career and fears somebody will die unnecessarily unless something is urgently done. “I have never in my whole career seen patients hanging off trolleys, vomiting down corridors, having ECGs down corridors, patients desperate for the toilet, desperate for a drin
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