As an agency scrub nurse, I was booked to work out of London in a private clinic. This was to work two nights and two days in theatres. It was my very first agency shift.
On the way to the theatres, escorted by a porter, I slipped on the stairs whilst holding on to the rails and fell, sustaining a right dislocated shoulder. I had it relocated in A&E in a local NHS hospital and was given entonox and morphine.
I returned to London the next morning – the taxi fare of £220 was not covered by the clinic.
I have now been unemployed for many weeks due to the injury. The Ag
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.
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
Recently Dr Peter Brennan tweeted a video of a plane landing at Heathrow airport during Storm Dennis. I looked at this with emotion, and with hundreds of in-flight safety information, human factors, communication and interpersonal skills running through my head.
I thought of the pilot and his crew, the cabin crew attendants and the passengers, and how scared and worried they would have felt. On a flight, the attendants will take us through the safety procedures before take off. We are all guilty, I am sure, of partly listening because it is routine and we have heard it all before. Then s
To use the tool, you just need to enter your height and weight into the online calculator, along with your height and weight 3-6 months ago. You will be given a rating that will tell you if you are at high, medium or low risk of malnutrition.
You will then be able to download a dietary advice sheet that gives basic information and suggestions for improving nutritional intake. If you are worried about your weight or having difficulty eating, make sure you talk to your GP or a healthcare professional.
The dietary advice sheet was developed in partnership with a number of professional o
What can I learn?
Managing human failures
Fatigue and shiftwork
Safety critical communications
Human factors in design
Maintenance, inspection and testing
Let's start with a summary of where we are in the blogs. I’m told our reader likes the summary (a Mrs Trellis of North Wales).
In part one we decided why we investigate an incident and what an incident was. In part two we decided that two investigators (or more) collect facts together in a more accurate way than one would. In part three we gazed into each other’s eyes and concluded that facts are our friends and where they might come from. We decided interviews and photos give us good facts. In part four we were introduced to what human factors is, and what it is all about and how western
The high complexity model is intended for services that have more complex pathways e.g. chronic (more than one year) services in acute, mental health or community services, where patients may return for several follow up appointments at intervals which may change depending on how their condition progresses.
You can use this model to inform decision making and planning, in supporting delivery of timely care to patients.
This web page includes the following tools:
high complexity model user guidance
demand and capacity: high complexity model (blank)
demand and capaci
I work in, both, the work imagined and prescribed, but practice in the world of work done.
It’s interesting working in both worlds and has made me ask these questions:
Why this happens?
What are the consequences?
How can we manage this disconnect?
A patient on a ward needs a nasogastric tube (NGT) for feeding and giving medication due to an impaired swallow following head and neck surgery.
The nurse prints off the policy for placing an NGT from the Trust's infonet.
The nurse inserts the NGT and checks the policy
Movies from 1939 are engrained in American culture. They share narrative, characters and quotes that people are aware of even if they, alas, haven’t seen the films. The list of films produced in what some consider the finest year in Hollywood history speaks for itself; it includes Stagecoach, Ninotchka, Destry Rides Again, Mr Smith Goes to Washington, The Wizard of Oz and both my and the Academy’s favourite, capping the impressive output with a December 1939 release, Gone with the Wind.
While recognising that certain characterisations in these movies haven’t aged well, the films have made
This document outlines ten key guidance points that designers of procedures should address at all stages of its development, implementation and review:
1. What is a work procedure?
2. Ensure a procedure is needed
3. Involve the whole team
4. Identify the hazards
5. Capture work-as-done
6. Make it easy to follow
7. Test it out
8. Train people
9. Put it into practice
10. Keep it under review.
An explanation of the discipline of Human Factors and Ergonomics (HFE) and the sub-discipline of human-centred design are also provided.