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Found 29 results
  1. Content Article
    This study in the Annals of Surgery aimed to characterise errors, events and distractions in the operating theatre, and measure the technical skills of surgeons in minimally invasive surgery practice. The authors of the study implemented the use of an operating room (OR) Black Box, a multiport data capture system that identifies intraoperative errors, events and distractions. The study found that the OR Black Box identified frequent intraoperative errors and events, variation in surgeons’ technical skills and a high number of environmental distractions during elective laparoscopic operations.
  2. Content Article
    Interruptions and multitasking are implicated as a major cause of clinical inefficiency and error. The aim of this study by Westbrook et al. was to measure the association between emergency doctors' rates of interruption and task completion times and rates.
  3. Content Article
    This study in The British Journal of General Practice aimed to quantify the time GPs spend on different activities during clinical sessions, to identify the number of operational failures they encounter and to define the nature of operational failures and their impact for GPs.
  4. Content Article
    The aim of this study from Mahadevan et al. was to understand human factors (HF) contributing to disturbances during invasive cardiac procedures, including frequency and nature of distractions, and assessment of operator workload. They observed 194 cardiac procedures in three adult cardiac catheterisation laboratories over 6 weeks. The study found that fewer than half of all procedures were completed without interruption/distraction. The majority were unnecessary and without relation to the case or list. The authors propose the introduction of a ‘sterile cockpit’ environment within catheter laboratories, as adapted from aviation and used in surgical operating theatres, to minimise non-emergent interruptions and disturbances, to improve operator conditions and overall patient safety.
  5. Content Article
    This list, produced by the Health and Safety Executive, bullet points the job, person and organisation factors that influence human performance.
  6. Content Article
    In this clinical case report for the Association of Anaesthetists, the authors reflect on the importance of error reporting and implementing learning from clinical mistakes. They look at several error-related incidents and examine key learning points. They highlight that cases that do not result in serious harm to the patient are not prioritised for entry into databases or national audits, meaning they are less likely to be the subject of system-based improvement projects when compared with more ‘serious’ events. They identify that this may cause gaps in clinicians' awareness of potential risks and error traps. The authors also examine the impact that learning projects based on incident reporting can have on clinicians involved in the initial incidents, highlighting that revisiting errors may prevent individuals from moving on from them.
  7. Content Article
    In this blog, a patient who experienced life-changing surgical complications describes the process of reconciliation between medical staff and patients when harm has occurred in healthcare. She highlights the need for both the patient and healthcare professional to be engaged and open in the process. She also looks at how different human factors can negatively impact on the duty of candour process, and why they need to be acknowledged. These factors include lack of communication, distraction, lack of resources, stress, complacency, lack of teamwork, pressure, lack of awareness, lack of knowledge, fatigue, lack of assertiveness and norms.
  8. Content Article
    Research undertaken by digital health platform, CAREFUL shows that handover in hospitals is the cause of frequent and severe harm to patients.
  9. Content Article
    Organisations expect to see consistency in the decisions of their employees, but humans are unreliable. Judgments can vary a great deal from one individual to the next, even when people are in the same role and supposedly following the same guidelines. And irrelevant factors, such as mood and the weather, can change one person’s decisions from occasion to occasion. This chance variability of decisions is called noise, and it is surprisingly costly to companies, which are usually completely unaware of it.
  10. Content Article
    An educational session from The Association for Perioperative Practice (AfPP) dedicated to the dangers of noise and distraction in healthcare with a possible solution, Below Ten Thousand. Below Ten Thousand is a language-based safety tool for any clinical arena where 'noise and distraction' is a problem, and where high performance teams need to quickly gain 'situational awareness' and ‘directed focus’ in order to successfully navigate the perils of acute healthcare whilst providing first class interventions. 
  11. Content Article
    In everyday life and in health care environments, distractions and interruptions are threats to human performance and safety. A distraction may occur when a driver is texting while in traffic or when a health care professional is interrupted during a high-risk task such as prescribing or administering a medication. Interruptions—ringing telephones, active alarms or computerized alerts, or even being asked a question – are ubiquitous in society, and health care is no exception. This article by nurse, Suzanne Beyea, discusses how mindfulness can reduced distraction and improve patient safety. Published by the Patient Safety Safety Network.
  12. Content Article
    Clinical decisions rarely occur in isolation. We must consider the social contexts in clinical environments and draw on theories of social emotion to help us better understand the influence of others’ emotion on our own thoughts, feelings and, ultimately, our ability to deliver safe care. In their Editorial in BMJ Quality & Safety, Jane Heyhoe and Rebecca Lawton explorie the role of social emotion in patient safety and looks at the recent research in this emerging area. They call on the patient safety community to embrace the idea that emotions and emotional contexts exert important impacts on healthcare delivery. Characterising these impacts will inform strategies for supporting staff and delivering safer and more effective care to patients.
  13. Content Article

    Why I ‘walk on by’

    I recently read the blog on the hub ‘Walk on by...’ by a junior doctor. What a fantastic doctor, if only we had more of these people in our healthcare service.  I wanted to respond to this blog by writing about my own experiences in ‘walking on by’. It’s been a difficult write as it has questioned my integrity, my motivation and my career.  
  14. Content Article
    Each baby counts is the Royal College of Obstetricians and Gynaecologist's national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. Watch the Each baby counts human factors video for information on how to address issues within your unit.
  15. Content Article
    Ben Tipney and Vikki Howarths' presetation on Human Factors in practice. This presentation covers: an introduction to human factors human factors training implementation of human factors in practice new initiatives.
  16. Content Article
    HindSight is a magazine produced by the Safety Improvement Sub-Group (SISG) of EUROCONTROL. It is produced for Air Traffic Controllers and is issued by the Agency twice a year. Its main function is to help operational air traffic controllers to share in the experiences of other controllers who have been involved in ATM-related safety occurrences.  The current Editor in Chief is Dr Steven Shorrock.
  17. Content Article
    The process of clinical consultation defines diagnosis and is crucial to patient safety and patient outcomes However the process is frequently weak resulting in care erring off path. These indicators (taken from a paper in Postgraduate Medical Journal) could provide a way to identify weaknesses and areas for improvement.
  18. Content Article
    Researchers have shown that people often miss the occurrence of an unexpected yet salient event if they are engaged in a different task, a phenomenon known as inattentional blindness. However, demonstrations of inattentional blindness have typically involved naive observers engaged in an unfamiliar task. What about expert searchers who have spent years honing their ability to detect small abnormalities in specific types of images? We asked 24 radiologists to perform a familiar lung-nodule detection task. A gorilla, 48 times the size of the average nodule, was inserted in the last case that was presented. Eighty-three percent of the radiologists did not see the gorilla. Eye tracking revealed that the majority of those who missed the gorilla looked directly at its location. Thus, even expert searchers, operating in their domain of expertise, are vulnerable to inattentional blindness.
  19. Content Article
    Reacting to a never event is difficult and often embarrassing for staff involved. East Lancashire Hospitals NHS Trust has demonstrated that treating staff with respect after a never event, creates an open culture that encourages problem solving and service improvement. The approach has allowed learning to be shared and paved the way for the trust to be the first in the UK to launch the patient centric behavioural noise reduction strategy ‘Below ten thousand’. Published in the Journal of Perioperative Practice.
  20. Content Article
    This edited book concerns the real practice of human factors and ergonomics (HF/E), conveying the perspectives and experiences of practitioners and other stakeholders in a variety of industrial sectors, organisational settings and working contexts.
  21. Content Article
    Below Ten Thousand is a language-based safety tool for any clinical arena where 'noise and distraction' is a problem, and where high performance teams need to quickly gain 'situational awareness' and ‘directed focus’ in order to successfully navigate the perils of acute healthcare whilst providing first class interventions. 
  22. Content Article
    In this BMJ article, James Reason discusses how the human error problem can be viewed in two ways: the person approach and the system approach. Each has its model of error causation and each model gives rise to quite different philosophies of error management. Understanding these differences has important practical implications for coping with the ever present risk of mishaps in clinical practice.
  23. Content Article
    In many safety-critical environments, including healthcare, operators need to remember to perform a deferred task, which requires prospective memory. Laboratory experiments suggest that extended prospective memory retention intervals, and interruptions in those retention intervals, could impair prospective memory performance.
  24. Content Article
    Potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies. This quality improvement study from Suliburk et al., published in JAMA Network Open, analysed the incidence of human performance deficiencies during the provision of surgical care to identify opportunities to enhance patient safety.
  25. Content Article
    The human factors ‘Dirty Dozen’ is a concept developed by Gordon DuPont. He described elements that can act as precursors to accidents or incidents, or influence people to make mistakes. This article by the Clinical Excellence Commission introduces the 'dirty dozen' and offers practical tips on how to reduced error int he workplace.
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