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Found 24 results
  1. News Article
    England’s poorest people get worse NHS care than its wealthiest citizens, including longer waiting for A&E treatment and worse experience of GP services, a new study has shown. Those from the most deprived areas have fewer hip replacements and are admitted to hospital with bed sores more often than people from the least deprived areas. With regard to emergency care, 14.3% of the most deprived had to wait more than the supposed maximum of four hours to be dealt with in A&E in 2017-18, compared with 12.8% of the wealthiest. Similarly, just 64% of the former had a good experience making a GP appointment, compared with 72% of those from the richest areas. Research by the Nuffield Trust and Health Foundation thinktanks found that the poorest people were less likely to recover from mental ill-health after receiving psychological therapy and be readmitted to hospital as a medical emergency soon after undergoing treatment. The findings sparked concern because they show that poorer people’s health risks being compounded by poorer access to NHS care. Read full story Source: The Guardian, 23 January 2020
  2. Content Article
    Medical error is the third leading cause of death in the U.S. After a routine partial hip replacement operation leaves the mother of filmmaker and comedian Steve Burrows in a coma with permanent brain damage, what starts as a personal video diary becomes a citizen’s investigation into the state of American healthcare.
  3. Content Article
    The People’s Covid Inquiry, chaired by the human rights lawyer Michael Mansfield QC, began in January 2021 to learn lessons quickly after the government rejected calls for a public inquiry. The Government was informed of the inquiry on 23 February 2021 and invited to take part. No response was received. The first session of the People’s Covid Inquiry began on 24 February and convened in live sessions fortnightly until 16 June 2021. The Inquiry took evidence over nine sessions from over 40 witnesses including international and UK experts, frontline workers, bereaved families, trade union leaders, and representatives of disabled people’s and pensioners’ organisations. 
  4. Community Post
    I am currently working to develop a new process for the investigation of incidents related to digital healthcare, something which clearly sits outside of the usual framework or process of investigating traditional patient safety incidents. I would be grateful for opportunities to discuss and share experiences and ideas with others. If you have already investigated these sort of incidents what sort of approach did you utilise and have you reviewed it post event in respect of effectiveness. @Keith Bates Clive has suggested it would be beneficial for us to discuss?
  5. Community Post
    Great blog in Learn from Martin on who should be in an investigation team - the expertise of the team, their roles and responsibilities. Do you agree?
  6. Content Article
    In my previous blogs I described the investigation process and where facts come from. We also pre-empted the content in this blog by saying that human factors (HF) is the scientific study of humans done by science types. It’s now time to talk ‘people’.
  7. Content Article
    When faced with a ‘human error’ problem, you may be tempted to ask 'Why didn’t these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable people in it.
  8. Content Article
    This article looks a some of the research into clinician burnout and the importance of early intervention. Perhaps the 72% of doctors, in a study in 2018, who said that they would go to work even when unwell or not resilient enough to work safely provides the most powerful evidence of this being both an organisational and individual problem that needs immediate attention.
  9. Content Article
    This Care Quality Commission (CQC) briefing document discusses the need for a change in the way that serious incidents are investigated and managed in the NHS. It is based on the findings of a review of a sample of serious incident investigation reports from 24 acute hospital trusts. This sample represented 15% of the total 159 acute hospital trusts in England at the time of review. The briefing provides a summary of the findings, linked to five opportunities for improvement and calls for all organisations to work together across the system to align expectations and create the right environment for open reporting, learning and improvement.
  10. Content Article
    This is part three of a series about the investigation process and human factors in healthcare. Part one looked at the why we investigate an ‘incident’. It concluded that there is only one reason to investigate – and that’s to stop the error occurring again. The idea that human factors is a science – done by science types was introduced. That facts are best collected by a minimum of two investigators. Pictures being our friend, and the cognitive interview concept was introduced. This part focuses on ‘Who’ should investigate and deals with the experience and expertise of the team, their roles and responsibilities in the light of the facts they will collect.  This blog is aimed at individual trusts and organisations rather than regulators/national bodies, etc.
  11. Content Article
    About one in ten patients are harmed during health care. Published on the OECD Library website, this paper estimates the health, financial and economic costs of this harm. Results indicate that patient harm exerts a considerable global health burden. The financial cost on health systems is also considerable and if the flow-on economic consequences such as lost productivity and income are included the costs of harm run into trillions of dollars annually. Because many of the incidents that cause harm can be prevented, these failures represent a considerable waste of healthcare resources, and the cost of failure dwarfs the investment required to implement effective prevention.
  12. Content Article
    Published in Systematic Reviews, this paper looks at how organisations need to systematically identify contributory factors (or causes) which impact on patient safety in order to effectively learn from error. Investigations of error have tended to focus on taking a reactive approach to learning from error, mainly relying on incident-reporting systems. Existing frameworks which aim to identify latent causes of error rely almost exclusively on evidence from non-healthcare settings. In view of this, the Yorkshire Contributory Factors Framework (YCFF) was developed in the hospital setting. Eighty-five percent of healthcare contacts occur in primary care. As a result, this review will build on the work that produced the YCFF, by examining the empirical evidence that relates to the contributory factors of error within a primary care setting.
  13. Content Article
    In their paper 'Managing risk in hazardous conditions: improvisation is not enough', Almaberti and Vincent ask "what strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to". This is clearly a critical and much overdue question, as many healthcare organisations are in an almost constant state of stress from high workload, personnel shortages, high-complexity patients, new technologies, fragmented and conflicting payment systems, over-regulation, and many other issues. These stressors put mid-level managers and front-line staff in situations where they may compromise their standards and be unable to provide the highest quality care. Such circumstances can contribute to low morale and burn-out. Eric Thomas discusses this further in his Editorial published in BMJ Safety & Quality.
  14. Content Article
    This is part two of a series about the investigation process and human factors in healthcare. Part one looked at the why we investigate an ‘incident’ and concluded that there is only one reason to investigate – and that’s to stop the error occurring again. The idea that human factors is a science – done by science types rather than by (deep breath) public speakers, non-technical skills (NTS) professionals, those who create team talks, medics who have been on a course about being nice and polite to other medics, and those that have married a human therefore they must be qualified to talk about humans – was also discussed. This and the next blog will introduce the concept of where facts or data comes from. Later blogs will deal with the who, how, when etc. The ‘who’ investigates (next blog) really is determined by where the facts come from. Later – if the cake lasts – we can chat about what to do with the data, and how to report it and save lives.
  15. Content Article
    A collection of resources from NHS Improvement to help you analyse, understand and improve the health and well-being of your workforce. Based on NHS Improvements's learning from the Improving Health and Well-being direct support programme, they have developed and collated some resources which will assist analysis of your quantitative and qualitative workforce data to drive and enable development of impactful evidence-based workforce health and well-being interventions.
  16. Content Article
    After completing nearly 600 investigations and research projects in human factors, it might be worth sharing some observations of why we do incident (forensic) investigations. This will be a series of short blogs that will cover the investigation process, answer questions about humans and shine a light on the method of forensic investigations.  This will be undertaken alternating with the topic of human factors – the most misunderstood bit of science the healthcare sector deals with. In these posts I’ll cover what human is, the limits of human performance – covering the senses, fatigue – and why pilots and CRM is very dangerous to healthcare. Above all I want to get the idea that human factors is a science and it’s about understanding how human limits restrict how we deal with the built environment and complex systems.
  17. Content Article
    This review by the Care Quality Commission included a sample of 74 investigation reports from 24 NHS acute hospital trusts, representing 15% of the 159 acute trusts in England.
  18. Content Article
    This study from Schnittker et al., published in Anaesthesia, aimed to identify which human factors were enablers and/or barriers to anaesthesia teams during airway management challenges.
  19. Content Article
    Was a lack of situational awareness a contributing factor in the outcome of this 'routine operation'? In this human factors video, Martin Bromiley, a pilot, explains what happened that day and what measures need to be in place to prevent other similar incidents.
  20. Content Article
    Part 6 of this series of blogs about human factors and investigations in healthcare discusses the 'How' and the 'Why'. How did the person die or was injured is different from understanding why it happened? At first this appears to be a pedantic, minor issue, but, as (hopefully) we shall see from this blog, it’s a vital distinction. Question How did the plane crash? Answer It was hit by a missile. Question Why was a missile launched, is a vastly different question. Question How was it that the pedestrian was hit by the car? Answer It was due to the driver not seeing them – but why did they not see them is the question.  Without the why – you can’t do the intervention. Most investigations done stop at the how – few get to the why, especially in medicine, especially with root cause analysis.
  21. Content Article
    This is part 5 of a series of blogs about human factors and investigations in healthcare. The theme is ‘when’ and that covers ‘when’ to investigate and ‘when’ to try any remedies or interventions your investigation data suggests might prevent the incident occurring again. As this blog can be explained by a photo and a graph, we have some time to recap the story so far and, perhaps, predict a bit of the future. 
  22. Content Article
    The responsibility of anaesthetists in prescribing and administering controlled drugs has extended not only to the recovery room and intensive therapy unit, but also to acute and chronic pain services both in hospital and home care. These guidelines written by the Association of Anaesthetists recommend best practice for the safe preparation, distribution and disposal of controlled drugs to meet current clinical demands in peri-operative care.
  23. Content Article
    The Care Quality Commission is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high quality care and we encourage care services to improve. Their role: They register health and adult social care providers. They monitor and inspect services to see whether they are safe, effective, caring, responsive and well-led, and we publish what we find, including quality ratings. They use our legal powers to take action where we identify poor care. They speak independently, publishing regional and national views of the major quality issues in health and social care, and encouraging improvement by highlighting good practice.
  24. Content Article
    Despite dealing with biomedical practices, infection prevention and control (IPC) is essentially a behavioural science. Human behaviour is influenced by various factors, including culture. This paper by M.A. Borg, published in the Journal of Hospital Infection, analyses the cultural determinants of infection control behaviour.
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