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Found 21 results
  1. Content Article
    Wrong tooth extraction has been clearly designated as a 'never event' since April 2015. However, in 2016/17, wrong tooth extraction topped the charts as being the most frequently occurring never event based on NHS England’s data. What can we do to mitigate these incidents? Based on both practical experience and research evidence, BAOS advises that the main methods for mitigation of errors are: learning from mistakes – including investigation and root cause analysis engaging the clinical team when developing 'correct site surgery' policies utilising the LocSSIPs template and guidelines from NHS England/RCS England developing a correct site surgery checklist that is appropriate for your clinical environment providing training for staff on the use of the checklist ensuring that the checklist is being used correctly through active audits of the processes involved supporting the clinical team throughout the process and not taking punitive action when incidents do occur.
  2. Content Article
    This paper from the British Medical Journal, describes specific examples of HFE-based interventions for patient safety. Studies show that HFE can be used in a variety of domains.
  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
    The Authors, conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff well-being. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff well-being.
  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
    In this book, Atul Gawande makes a compelling argument for the checklist, which he believes to be the most promising method available in surmounting failure. Whether you're following a recipe, investing millions of dollars in a company or building a skyscraper, the checklist is an essential tool in virtually every area of our lives and Gawande explains how breaking down complex, high pressure tasks into small steps can radically improve everything from airline safety to heart surgery survival rates.
  7. Content Article
    In this blog, Steven questions: Are we reducing the human to ‘human error’? Are we reducing the human to a faulty information processing machine? Are we reducing the human to emotional aberrations? Are we reducing human involvement in socio-technical systems?
  8. 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.
  9. Community Post
    Hi I have been working in a presentation we are giving at ASPiH in November around the work we have done using simulation to test systems and processes. we have done this in two ways. Firstly as a by-product of an educational in situ simulation in s clinical environment where a latent threat has been identified. In this case we will work with the area in looking at just what contributes to the threat and ways that may help. The second way (and with my HF head on, more exciting) has been setting out to test a process. We have done this several times now and have had some real successes in demonstrating the work as done v work as imagined theory. has anyone else used simulation in this way? looking forward to your replies. Phil
  10. 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 anyone know of any work on human factors in hospital design to deliver safer care (processes, equipment, layout, technology etc)? In the UK or internationally? By googling I've found articles on specific departmental inititaives and people calling for more to be done but not much of the 'how' or any requirment to embed patient safety into new build hospital deisgn. Surely there must be soemthing?!!
  11. Content Article
    What can I learn? Managing human failures Staffing Fatigue and shiftwork Safety critical communications Human factors in design Procedures Competence Organisational change Organisational culture Maintenance, inspection and testing
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