The gap was illustrated through an investigation that focused on a case of wrong tooth extraction. Wrong tooth extraction was categorised as a Never Event and therefore HSIB sought to understand the ‘barriers’ that exist in the pathway of care for wrong tooth extraction.
The report identifies that while there are controls in place to prevent wrong tooth extraction, they invariably rely on staff to be effective and should not be regarded as ‘strong systemic protective’ barriers. The investigation went further to examine the differences in how the NHS defines and assures barriers in compari
Join the Airport Training Experts Miroslav SPAK and Frederic Rooseleer for a 90 minutes live training session.
Enhanced operational efficiency and sustainability can be achieved by optimising the current operations through implementation of advanced solutions maximizing utilisation of the airport capacity. These solutions have been initially developed and validated under SESAR, and recently packaged by EUROCONTROL to cover Runway Performance, Surface Management and Total Airport Management.
This webinar will provide information on the total airport management building blocks and also a r
Learning from Excellence (LfE) is a system for capturing examples of good practice in healthcare as a complementary approach to traditional incident reporting.
The LfE philosophy proposes that learning from what works well in a system enables improvements in the quality and safety of the work, and the morale of staff performing it.
LfE systems comprise simple reporting forms for peer-to-peer positive feedback with sharing of examples to enable wider learning.
LfE reporting identifies excellence and learning opportunities in both process and outcome.
The goals of this Just Culture Manifesto are to:
articulate a vision of just culture that connects with people from all industrial sectors, around the world;
speak to people in all roles – front line, support, specialists, management, both in private industry, government organisations and departments, and the justice system;
provide a framework for other people to advance this vision of just culture.
As referred to in the Just Culture definition, only a very small proportion of human actions is criminally relevant (criminal behaviour, such as substance abuse or misuse, gr