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Found 28 results
  1. Content Article
    Handover in hospitals is the cause of frequent and severe harm to patients, according to new research* by digital health platform, CAREFUL. Many patients are suffering because handover is poorly controlled and under-recognised as a source of clinical risk. Handover is the transfer of responsibility and crucial patient information between practitioners and teams. Handover takes place when shifts change and when patients are transferred between departments or outside of the hospital into another care setting. This is a time when staff are under pressure and when mistakes can happen – as the research shows. “We undertook this research because little is known about how practitioners see the risks of handover and the impact of handover on patient safety,” says CAREFUL CEO, Dr DJ Hamblin-Brown. “We anticipated that doctors and nurses would report some errors, but the frequency with which harm is reported across the world is disturbing.” Patient safety in operating theatres has been a recognised problem for many years – ever since the publication of the original checklist article in the New England Journal of Medicine. By contrast, handover, despite being possibly the most common clinical process across healthcare, has not been studied so widely. CAREFUL’s research investigated clinicians’ experience of handover, receiving 432 completed responses from clinicians in 26 countries via an open, anonymous and confidential online questionnaire. Published in February 2022, the findings revealed that errors in handover occur weekly or daily, according to 12% of respondents. Nearly 10% had witnessed severe harm – either death or otherwise life changing – because of handover error. “Handover takes place about 4,000 times each day in a typical teaching hospital”, explains Dr Hamblin-Brown. “It is a procedure prone to a multitude of errors due to reliance on paper that’s easily lost or verbal discussion that’s easily forgotten.” One of the most worrying findings in the research is that most handover takes place using a many different support systems; 35% are still using handwritten notes; 21% are using office documents such as Word and Excel; 10% write on whiteboards and a full 15% are using unofficial messaging apps like WhatsApp. Healthcare leaders reflect the same concerns as staff, but they specifically also want more access to patient information and better electronic systems. Digital platforms may be the only real solution to the challenges surrounding handover, with the ability to provide safe and secure access to handover information at the swipe of a screen that is neither lost nor forgotten. “We work in an industry that is failing to take seriously the dangers of handover. It is arguably the most common, and one of the most important, processes. We harm both staff and patients if we fail to address the dangers of handover,” concludes Dr Hamblin-Brown. *This paper is in pre-print and has not yet been peer-reviewed.
  2. Content Article

    Why I ‘walk on by’

    Anonymous
    Walking by is not what I want to do but walking by is what I do on a regular basis. I am ashamed to write this, to think this, to do this. I don’t think I am alone as I have seen others do it too. We are not bad people, but I can’t help but think that we have turned into bad nurses. The last thing I wanted to be was a bad nurse. This was never the plan… it’s crept in, without me knowing it was happening. Until now. How has this happened? How have I become the nurse I despise? I work on an acute medical admissions unit. We have patients that are admitted from the emergency department (ED). They are unwell, often too unwell to come to us, but patients need to be moved. “Keep ED flowing” – its all about flow. I have begun to hate that word. We have 36 beds in total. We have a nurse/patient ratio of 1:6. Sometimes 1:8 if we are short staffed. Throughout the day we can have up to 12 patients that have passed through those six beds. They go to other medical wards, respiratory wards… anywhere that has space. If we have no room the ED gets backed up and ‘flow’ stops. I have pressure from my nurse in charge to move my patient to another ward, they have pressure from the bed manager, who has pressure from the ops manager. I have sat in on bed meetings, it’s not easy listening. A high up manager barking “we need 45 discharges by mid-day”; it’s not achievable… it goes on every day. I’m getting these patients ready for transfer. Safety booklets, pages long to be completed: nutritional score, waterlow score, bowel chart, touch the toes chart, fluid chart, turns chart, fall proforma, NEWS charting, food chart, clinical pathways, next of kin contact details, let alone my documentation for those few hours they have sat in that bed. All the while, drugs need to be given, intravenous drugs, not just for my patient but I have to help the agency nurse in the next bay as “she can’t do IVs”. Patients need washing, turning, feeding, monitoring, bloods to be taken, wounds to be dressed, hourly pump checks, blood sugar testing, cannulation and conversations with sick patients’ relatives. These are tasks that need to be done on time. If not – trust policy is breached. Some, I just ‘tick’, especially if it’s a checklist. I know I’m not the only one that does this – it’s normal. So, when I’m in the middle of trying to complete these ever-growing tasks, I hear “nurse can you…” “nurse will you just…” “I know you're busy but...” What do I do? I walk on by. I walk at high speed. I have stopped before. It often stops me completing my tasks. I forget what I was meant to be doing. I have missed a crucial blood sugar check for my DKA patient in the past. Patients do not get their medication on time, patients are not transferred on time (it’s all about the flow), safety booklets not completed, handovers rushed and information missed, documentation scant. I’m always in a rush. I know many of the calls are for toileting. This can take a while. I daren’t look at the pressure areas – my heart sinks if there is one… more documentation, more time away from the other tasks. Patients who come in are often at risk of falling, so need two people to help. I know the next-door nurse is just as busy; I feel bad to ask her/him. The healthcare assistant is often too busy to help, getting patients ready for transfer, doing the observations… relentless. Walk on by. Yes, I do. I am not the only one. What are the Trust priorities? Safe care or flow? The Trust will always say safe care. So why set up the environment that causes unsafe care? Mixed messages. I became a nurse to give evidence-based, holistic, safe care. I go home demoralised. I don’t recognise this profession anymore.
  3. Content Article
    Key themes: Situational awareness Handover resources Interruptions and distractions Delegation Task-fixation, helicopter view & closed-loop communication Ask for help.
  4. Content Article
    This issue of Hindsight includes articles on: Malicious compliance by Sidney Dekker Can we ever imagine how work is done? by Erik Hollnagel Safety is in the eye of the beholder by Florence-Marie Jegoux, Ludovic Mieusset and Sébastien Follet I wouldn't have done what they did by Martin Bromiley
  5. Content Article
    The book blends literature on the nature of practice with diverse and eclectic reflections from experience in a range of contexts, from healthcare to agriculture. It explores what helps and what hinders the achievement of the core goals of human factors and ergonomics (HF/E): improved system performance and human wellbeing. The book should be of interest to current HF/E practitioners, future HF/E practitioners, allied practitioners, HF/E advocates and ambassadors, researchers, policy makers and regulators, and clients of HF/E services and products.
  6. Content Article
    The operating theatre works daily by the premise of ‘surgical precision’. Every opportunity to work as a holistic team is embraced, not only as an effective way to get things done, but also as a way to maximise patient safety and reduce risk. Given the intensity of the work and the mandatory desire for a good outcome, surgeons, anaesthetists, nurses and theatre technicians are embracing a new concept in operating theatre team dynamics. The concept has been developed by nurses at Geelong Hospital. John Gibbs, a Clinical Nurse Specialist in Anaesthetics, studied Crew Resource Management strategies common in the airline industry and found that some dimensions of aeronautical crew resource engineering could solve dilemmas in his operating theatre environment, in particular, the reduction of ambient noise and distractions at sentinel times of anaesthesia. In collaboration with other staff, he has worked on and improved upon the idea, finally arriving at the prototype concept of ‘Below Ten Thousand’ for the surgical and clinical setting.
  7. Content Article
    Key learning points Two approaches to the problem of human fallibility exist: the person and the system approaches. The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness. The system approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects. High reliability organisations—which have less than their fair share of accidents—recognise that human variability is a force to harness in averting errors, but they work hard to focus that variability and are constantly preoccupied with the possibility of failure.
  8. Content Article
    The aim of this study, published in Human Factors journal, was to examine the effects of interruptions and retention interval on prospective memory for deferred tasks in simulated air traffic control. This can be translated into a healthcare environment.
  9. Content Article
    From the 5365 operations, 188 adverse events were recorded. Of these, 106 adverse events (56.4%) were due to human error, of which cognitive error accounted for 99 of 192 human performance deficiencies (51.6%). These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.
  10. Content Article
    The study examined the work of 61 GPs working in the NHS using time-motion methods, ethnographic observations and interviews. It found that GPs’ work is frequently disrupted by operational failures including: missing patient information problems with technology interruptions to consultations. The study identifies the nature and impact of operational failures that GPs face, allowing for more specific improvement measures to be explored. It also indicates the need for coordinated action to support GPs.
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