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Showing results for tags 'High reliability organisations'.
Found 37 results
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Content ArticleIn healthcare, errors could have serious consequences for patients and staff. High-risk industries, such as aviation, have improved safety by taking a systems approach, known as safety management systems. Safety management systems are generally considered to have four key components: leadership commitment and safety policy; safety risk management; safety assurance; and safety culture. Safety management systems need to be context-specific to be effective. Evidence on the use of safety management systems in health care is therefore needed to inform policy decisions. A systematic review was undertaken to investigate the application of safety management systems to patient safety in terms of effectiveness, implementation and experience. The authors included evidence from Australia, Canada, Ireland, the Netherlands and New Zealand because their healthcare systems are similar to the United Kingdom’s. They included policy documents, research papers and accounts of patient and staff experiences. The study found that the Netherlands was the only country with a patient safety programme explicitly based on a safety management system approach. The programme was associated with improvement in some aspects of patient safety in hospitals but there was significant variation in its implementation and outcomes. The main components of a safety management system were also identified to some extent in the patient safety approaches of the other four countries, along with evidence of influence from high-risk industries and ‘safety science’ more widely. Across all five countries, there was a change in the patient safety discourse away from the narrow focus on reporting and learning from incidents. Without denying the importance of this element, the new approaches to patient safety adopted broader definitions of safety (e.g. including psychological and cultural safety) and harm (e.g. including harm resulting from social inequalities and structural oppression), and emphasised the importance of taking a systems perspective and involving everybody, especially patients and families, in the processes of assessing and creating safety, and learning from successful practice as well as failures. Although these new ideas were present in the policies of all countries, their translation into practice was not always clear, and robust evidence of their effectiveness was not available. Although there is a considerable overlap between the Dutch PSP and the NHS patient safety strategy in terms of specific components, one important difference is the role of leadership within individual healthcare organisations. While the role of leadership is also acknowledged in the NHS patient safety strategy, the responsibilities of the top management and the lines of accountability in relation to patient safety within a healthcare organisation are not always clearly defined. The responsibilities of local patient safety specialists are most clear but they may not have the authority or capacity to ensure patient safety throughout the organisation.
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Content ArticleArtificial intelligence (AI) and machine learning (ML) are being used and tested in numerous ways. This review highlights how they are being used to detect and mitigate human error in safety-critical industries, the limitations and challenges of AI/ML, and insights from the recent literature. Examples from health care include using AI to detect diagnostic errors and combining AI with clinician expertise, with the ultimate decision to follow AI’s suggestion resting with the clinician.
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Content ArticleIdentifying high and poorly performing organisations is common practice in healthcare. Often this is done within a frequentist inferential framework where statistical techniques are used that acknowledge that observed performance is an imperfect measure of underlying quality. Various methods are employed for this purpose, but the influence of chance on the degree of misclassification is often underappreciated. Using simulations, this study shows that the distribution of underlying performance of organisations flagged as the worst performers, using current best practices, was highly dependent on the reliability of the performance measure. When reliability was low, flagged organisations were likely to have an underlying performance that was near the population average. Reliability needs to reach at least 0.7 for 50% of flagged organisations to be correctly flagged and 0.9 to nearly eliminate incorrectly flagging organisations close to the overall mean. The authors conclude that despite their widespread use, techniques for identifying the best and worst performing organisations do not necessarily identify truly good and bad performers and even with the best techniques, reliable data are required.
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Content ArticleMany healthcare networks strive to become a high reliability organisation (HRO)—an organization that maintains a safe environment despite the challenges and complexities of its daily operations, many of which are considered high-risk. This study in Patient Safety looks at how Ascension health, a multistate health system, has built a customised learning management system to help it become a HRO. Network-based learning systems have been recognised as an effective way to share knowledge and collaborate toward safety, but there has been little published on how they have been applied in healthcare organisations. A team at Ascension has been developing a comprehensive learning management network that provides continuous, widespread patient safety education through various channels, including event reporting, data analysis, storytelling and causal analysis. This article shares the lessons they learned about what did and didn’t work and promising strategies. These insights can be used by other health systems who want to introduce a similar framework to foster a supportive environment for patient safety.
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Content ArticleThis article in Time reviews the documentary film 'To Err is Human', which explores the tragic outcomes of medical errors and the medical culture that allows them to persist. The film follows the Sheridans, a family from Boise, Idaho on their journey to understand how two major medical errors befell their family: one that contributed to a case of cerebral palsy, and another that involved a delayed cancer diagnosis and ended in death.
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Content ArticleThis study in BMJ Open Quality examines aspects of workplace culture, employee motivation and leadership behaviours that support continuous learning and improvement, in an effort to measure the transition to high reliability. It reports on the development of two scales (trust in team members and trust in leadership) in a US children’s hospital which was seeking to assess progressive movement towards a ‘culture of safety'. The scales were designed to measure two cultural conditions fostered by the five high reliability principles and a composite measure on local learning activities.
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Content ArticleHealthcare can be risky. Adverse events carry a high cost – both human and financial – for health systems around the world. So in an effort to improve safety, many health systems have looked to learn from high-risk industries. The aviation and nuclear industries, for example, have excellent safety records despite operating in hazardous conditions. And increasingly, the tools and procedures these industries use to identify hazards are being adopted in healthcare. One prominent example involves the Hierarchy of Risk Controls (HoC) approach, which works by ranking the methods of controlling risks based on their expected effectiveness. According to HoC, the risks at the top are presumed to be more effective than those at the bottom. The ones at the top typically rely less on human behaviour: for example, a new piece of technology is considered to be a stronger risk control than training staff. This article looks more deeply at the (HoC) approach to explore its usefulness and effectiveness in healthcare. To investigate this issue, a team of social scientists examined the risk controls introduced by four hospital teams in England and Scotland after they had identified hazards in their systems. Findings: Most of these risk controls – 35 out of 42 – would be classified as ‘administrative’ by the HoC, and thus considered weak. The risk controls that fell into this ‘administrative’ category included training, standardising processes and procedures, and changing the design and organisation of care. Since other evidence shows these approaches can sometimes be very successful in healthcare, it is probably a mistake to automatically assume they are weak. Completely eliminating reliance on human behaviour is very difficult in the healthcare context and would introduce new risks. A rigid hierarchical approach to classifying risks may not be right for healthcare. Caution is needed before abandoning apparently weak interventions. Learning from other industries may be useful, but it is not always straightforward.
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Content Article
Skybrary: Safety Management System in aviation
Patient Safety Learning posted an article in Organisational
The objective of a Safety Management System is to provide a structured management approach to control safety risks in operations. Effective safety management must take into account the organisation’s specific structures and processes related to safety of operations. -
Content ArticleFor two decades, Swiss Cheese theory has been an influential metaphor in safety science and accident prevention. It has made barrier theory and the impact of safety culture on operational safety more understandable to the upper echelons of high-risk organisations in many industrial sectors. Yet sometimes the Swiss Cheese model is used to focus on the operational ‘sharp end’ and unsafe acts, like a magnifying glass that acknowledges organizational influence, but still targets the human operator. It is time to ‘turn this lens around and allow organisations to focus on the upstream factors and decision-making that can engender these unsafe acts in the first place. This paper reports on an approach to do this, under development in the Maritime sector, called Reverse Swiss Cheese.
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Content ArticleThis open access book addresses the future of work and industry by 2040—a core interest for many disciplines inspiring a strong momentum for employment and training within the industrial world. The future of industrial safety in terms of technological risk-management, although of obvious concern to international actors in various industries, has been quite sparsely addressed. This brief reflects the viewpoints of experts who come from different academic disciplines and various sectors such as oil and gas, energy, transportation, and the digital and even the military worlds, as expressed in debates and discussions during a two-day international seminar. 'Managing future challenges for safety' will interest and influence researchers considering the future effects of a number of currently developing technologies and their practitioner counterparts working in industry and regulation. The book addresses such questions as: What influence will ageing and lack of digital skills in the workforce of the occidental world have on safety culture? What are the likely impacts of big data, artificial intelligence and autonomous technologies on decision-making, and on the roles and responsibilities of individual actors and whole organizations? What role have human beings in a world of accelerating changes? What effects will societal concerns and the entrance of new players have on technological risk management and governance?
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Content ArticleThe Leapfrog Group is a non-profit watchdog organisation that serves as a voice for healthcare consumers in the US, using their collective influence to foster positive change in healthcare. It provides patient safety ratings for hospitals, grading them from A to E. This article in Becker's Hospital Review highlights the patient safety priorities for 2023 of eleven US hospitals that have consistently been awarded 'A' grades by Leapfrog. Key themes include a focus on reducing healthcare associated infections, increasing psychological safety for staff and improving communication between staff and patients.
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Content Article
Rethinking healthcare as a safety-critical industry
Patient Safety Learning posted an article in Barriers
The discipline of ergonomics, or human factors engineering, has made substantial contributions to both the development of a science of safety, and to the improvement of safety in a wide variety of hazardous industries, including nuclear power, aviation, shipping, energy extraction and refining, military operations, and finance. It is notable that healthcare, which in most advanced societies is a substantial sector of the economy and has been associated with large volumes of potentially preventable morbidity and mortality, has not up to now been viewed as a safety critical industry. This paper from Robert L Wears proposes that improving safety performance in healthcare must involve a re-envisioning of healthcare itself as a safety-critical industry, but one with considerable differences from most engineered safety-critical systems. This has implications both for healthcare, and for conceptions of safety-critical industries. -
Content ArticleEurocontrol’s HindSight magazine is a magazine on human and organisational factors in operations, in air traffic management and beyond. This issue has articles from front-line staff and specialists in safety, human factors, and human and organisational performance, in aviation and elsewhere. The articles cover all aspects of everyday work, including routine work, unwanted events, and excellence. The authors discuss a variety of ways to learn from everyday work, including observation, discussion, surveys, reflection, and data analysis. There are articles on specific topics to help learn from others’ experience, including from other sectors in ‘views from elsewhere’
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Content ArticleSleep deprivation and fatigue lead to a wide range of performance issues that may pose risks to workers and others in the work environment. This review in Frontiers in Neuroscience discusses relevant literature on the topic of fatigue-related performance effects, with a special emphasis physiological and behavioural response variables that have shown to be sensitive to changes in fatigue. It also looks at methods for mitigating these performance effects and discusses their usefulness in regulating them.
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Content Article
Guiding principles for determining work shift duration and addressing the effects of work shift duration on performance, safety, and health: guidance from the American Academy of Sleep Medicine and the Sleep Research Society (1 November 2021)
Patient-Safety-Learning posted an article in Workforce and resources
Regulators, organisations, communities and workers often struggle with how to manage shift duration and address associated risks from fatigue and sleepiness, while continuing to meet the societal demands for work. This article in the Journal of Clinical Sleep Medicine proposes a series of guiding principles help design a shift duration decision-making process that effectively balances the need to meet operational demands with the need to manage fatigue-related risks. -
Event
Human Factors in accident investigation
Patient Safety Learning posted an event in Community Calendar
untilThis free webinar will uncover the intricacies of accident investigation from a human factors perspective. It will feature examples from rail, air and maritime from our speakers who are all specialist human factors investigators. Hear first hand how they tackle investigations and get insights into this vital work that lead to improvements in safety across all travel sectors. Will Tutton will briefly mention the Herald of Free Enterprise, but will mainly talk about the cargo vessel Kaami, which ran aground in Scotland in March 2020. The investigation focused on front line operators. Lisa Fitzsimons will talk about common themes relating to human performance and organisational factors which emerge when investigating the technical aspects of an air accident, drawing upon several recent examples. Becky Charles will discuss track worker safety and specifically about an incident which occurred at Margam, UK in July 2019 where two trackworkers were struck and fatally injured. Register -
Content Article
In a series of blogs for the hub, Emma Plunkett and Nancy Redfern, part of the Joint Working Group on Fatigue, will highlight the impact staff fatigue has not only on the staff themselves but also on patient safety, and why healthcare needs a robust fatigue risk management system like other safety-critical industries. In their first blog, Emma and Nancy share how they became involved in investigating night shift fatigue after the death of a colleague driving home tired. They discuss how they set up the Joint Working Group on Fatigue and the aims of the #FightFatigue campaign. Our story started with a tragedy. We all knew the feeling of overwhelming tiredness after a busy night shift but, until one of our anaesthetic trainees died driving home tired, we had just thought of it as an occupational hazard. As we investigated the problem, we realised that other safety-critical industries, such as airline, electric and rail, had formal ways of managing night shift fatigue. We needed to do the same. Evidence of the effects of fatigue We started with a survey of all trainees in anaesthesia in the UK, partly to raise awareness of the impact of fatigue and partly to find out how common driving accidents were. Alarmingly, 57% of trainees described having an accident or near miss driving home. The robust response rate and the scale of the issue identified led to publication of our findings in the journal Anaesthesia.[1] What had previously been anecdotal accounts was now evidence. As soon as this was published, the consultants said ‘me too’, so we surveyed them. 91% of the consultants reported experiencing work-related fatigue with 50% expressing that this had a negative impact on their physical and psychological wellbeing. A concerning 45% had had an accident or near miss driving home after a long shift or a night on call at some point in their career. Although both groups recognised they were very tired, many felt they had no choice but to drive as there were no facilities to rest in the hospital during or after a night shift. And three-quarters of them used their car to get to and from work.[2] Our working patterns have changed massively in recent years. The introduction of the European Working Time directive meant that trainees moved to 12-hour shifts and managers removed the on-call rooms in many hospitals. Consultants often do 12-hour days and spend many hours working alone, sometimes followed by a night on call. Relentless growth in our workload, gaps in rotas and lack of staff all make shifts busier and contribute to high levels of fatigue in healthcare staff. #FightFatigue campaign Realising the size of the problem, we established a joint working group on fatigue, with the Association of Anaesthetists, the Royal College of Anaesthetists (RCoA) and the Faculty of Intensive Care medicine. We designed some educational material, posters and teaching materials, and started to do talks and workshops wherever and whenever we were invited. The #FightFatigue campaign was underway. Introducing the 20-minute power nap But there was no point in just talking; people also needed somewhere to rest near where they work. Research into other industries showed that as little as a 20-minute power nap might prevent ‘microsleeps’ – the few seconds’ lack of awareness of our surroundings that probably killed the trainee driving home. Other impacts of fatigue, on logical reasoning, vigilance, flexibility of thinking and creativity, memory and learning, and empathy, might also be improved by a power nap. Some organisations bought sofas that could be turned into couches to nap on in the coffee room, others got sleep pods. The BMA published a fatigue and facilities charter.[3] During the pandemic, they also provided funds for hospitals to buy roll out chairs and sofa beds to help staff rest. A few hospitals spent the money Sir Tom Moore raised by walking round his garden on rest facilities. We wanted to track whether these initiatives had led to sustained change. The General Medical Council conducts an annual National Training Survey of all junior doctors and educational supervisors, so we approached them to ask to have questions on fatigue included in this. With the support of the RCoA, trainees in anaesthesia have been asked questions related to fatigue since 2018. Although there is still room for improvement, it has been encouraging to see a trend towards better support for breaks, fewer trainees feeling too tired to drive and improved availability of education on fatigue and shift working. Organisational culture Providing education and facilities is a good first step, but real change depends on leadership and a supportive night shift culture. It’s not enough to know how to manage fatigue; we all have to put our knowledge into practice, even on busy shifts, and this depends on the team. We were awarded some funding from the Health Foundation and conducted a project in one hospital labour ward, identifying what the specific risks of staff fatigue are for our staff and strategies to mitigate them. Our latest venture is to encourage other departments to put fatigue on the risk register, with proactive elements to try and prevent fatigue and reactive elements so that staff are managed well if they are critically tired. Looking to other industries Other organisations are also interested in our work. We were thrilled to be contacted by the Healthcare Safety Investigation Branch (HSIB), the equivalent of the Air Accident Investigation Branch who review serious incidents. They too felt that staff fatigue deserves more attention. Next we need to get patients involved. There must be lots of people who have worked in airline, nuclear, rail or petrochemical industries who would expect a robust approach to staff fatigue, who can help us persuade hospitals and governments that healthcare deserves what other industries have. This hasn’t been a project with targets and timelines. Rather, we know where we want to get to – to have robust fatigue risk management systems in healthcare similar to those in other safety-critical industries. We haven’t got the power to do this, all we have is influence. I describe it as tipping out the pieces of a large jigsaw puzzle; some pieces are the right way up, some go together, but there’s a lot of turning over pieces and trying things out. Whenever an opportunity presents itself, we try and take it, raising awareness, sharing learning, encouraging change and auditing progress. Working with HSIB and Patient Safety Learning is a real milestone for us – they will have influence where we do not. Good management of staff fatigue will improve safety and wellbeing for staff and, ultimately, will make patient safer. Our next blog In our second blog, we will discuss managing fatigue as part of a safety culture References McClelland L, Holland J, Lomas J-P, et al. A national survey of the effects of fatigue on trainees in anaesthesia in the UK. Anaesthesia 2017;72 (9): 1069-77. https://doi.org/10.1111/anae.13965. McClelland L, Plunkett E, McCrossan R. A national survey of out-of-hours working and fatigue in consultants in anaesthesia and paediatric intensive care in the UK and Ireland. Anaesthesia 2017; 74 (12): 1509-23. https://doi.org/10.1111/anae.14819. British Medical Association. BMA Fatigue and Facilities charter. July 2018. Further resources on fatigue Association of Anaesthetists fatigue resources. Fatigue resources on the hub. -
Content ArticleThis podcast by the National Patient Safety Board asks how healthcare can address the systemic challenges that have prevented progress on patient safety for decades. Hosted by Karen Wolk Feinstein, this episode looks at lessons that can be taken from other industries that have made safety a top priority. Karen talks to guests Professor Nancy Leveson, engineer and systems safety expert, and Dr. Michael Shabot, former healthcare executive and expert in high-reliability healthcare safety and quality.
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EventObjectives: Describe the steps involved in conducting RCA of an error. List the tools that can be used during the RCA process. Identify who should be included on a debriefing team and what the ground rules are that will allow a debriefing meeting to be most effective. Register
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EventuntilIt’s time to register for the 2022 World Patient Safety, Science & Technology Summit, hosted by Patient Safety Movement in the USA. The 2022 World Patient Safety, Science & Technology Summit (WPSSTS) is co-convened by the American Society of Anesthesiologists, the European Society of Anaesthesiology and Intensive Care and the International Society for Quality in Health Care, and will celebrate the Patient Safety Movement Foundation’s first 10 years of achievements. The 2022 WPSSTS will confront leading patient safety issues with actionable ideas and innovations to transform the continuum of care by dramatically improving patient safety and eliminating preventable patient harm and death. The WPSSTS brings together all stakeholders; we need everyone to step up and be part of the solution. We invite international hospital leaders, patient and family member advocates who have experienced harm, public policymakers and government officials, other non-profits working toward zero harm, healthcare technologists, engineers, and the future of healthcare – students and residents. All stakeholders are invited to actively and intimately plan solutions around the leading patient safety challenges that cause preventable patient deaths in hospitals and healthcare organizations worldwide. The WPSSTS will also feature keynote addresses from public figures, patient safety experts, and plenary sessions with healthcare luminaries, patient advocates, as well as announcements from organizations who have made their own commitments to reach the Patient Safety Movement Foundation’s vision of ZERO preventable harm and death across the globe by 2030. Event timings: 4 March 2022 8.00 am PST (4.00pm GMT) - 5 March 2022 5.00 pm PST (6 March 1.00am GMT) Buy tickets
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Content ArticleProfessor Ron McLeod's presentation on the Chartered Institute of Ergonomics & Human Factors (CIEHF) White Paper on Human Factors in highly automated systems.
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Content ArticleClinical engagement has supplemented clinical governance in healthcare to strengthen the contribution of medical professionals to the assessment of clinical outcomes for patients. Assessments of clinical engagement have, until now, been qualitative; this case study in the journal Australian Health Review introduces the concept of quantitative assessment of clinical engagement by measuring the number of patients managed according to specialist society guidelines. Such an assessment engages all staff (medical, nursing, allied health and pharmacy) involved in patients receiving treatment according to such guidelines and provides an assessment of individual and organisational compliance with those guidelines. Clinical engagement is then quantified as the percentage of patients that have been documented to receive specialist society- or college-approved guideline-compliant treatment, relative to the total number who could receive such treatment, in any healthcare organisation.
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Content ArticleThis Chartered Institute of Ergonomics and Human Factors (CIEHF) webinar explores near misses in three different sectors and how controls can, or cannot, be developed to prevent future events. The webinar starts with an introduction to the concept of near misses in healthcare and the challenges faced in learning from these near misses to improve safety. You will then hear how near misses are approached in rail and nuclear and how controls are developed in their processes. You will: Gain valuable insights from all three sectors: healthcare, rail and nuclear. Hear discussion about defining near misses with respect to controls. Learn how to build barriers in systems.
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Content ArticleHuman error is as old as humankind itself and widely recognised as a significant cause of mistakes. Much of the research in this area has originated from high-risk organisations (HROs), including commercial aviation, where even simple mistakes can be catastrophic. A failure to understand and recognise how Human Factors (HF), especially those that affect performance and team working, can contribute or lead to serious medical error is still widespread across healthcare. Sadly, this commonly occurs in the operating theatre, one of the most dangerous places in hospital. While attitudes and acceptance of pre-surgery briefings has improved using the World Health Service (WHO) Surgical Checklist, this does not address other 'personal' factors that can lead to error, including stress, fatigue, emotional status, hunger and situational awareness. Following initial work around HF perception amongst operating theatre teams, Peter Brennan's (student at the University of Portsmouth) research has lead to significant delivery changes to the high stakes Membership of the Royal College of Surgeons (MRCS) examination, taken by up tp 6,500 junior doctors per year. After recognising boredom and fatigue in examiners, further published studies found an improvement in examiner morale with no significant changes in exam reliability or overall candidate outcome. These changes have improved patient safety at a National level. Other high stakes National Events have been evaluated where repetitive assessment occurs during long days, providing reassurance to organisers and the General Medical Council. 28 HF-related publications have been included in this work, including several reviews of important personal factors that affect performance and how these can be optimised at work.
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Content Article
Deference to expertise: Making care safer (2017)
Patient Safety Learning posted an article in Good practice
Since the seminal report by the Institute of Medicine, To Err Is Human, was issued in 1999, significant efforts across the health care industry have been launched to improve the safety and quality of patient care. Recent advances in the safety of health care delivery have included commitment to creating high-reliability organisations (HROs) to enhance existing quality improvement activities. This article will explore key elements of the HRO concept of deference to expertise, describe the structural elements that support nurses and other personnel in speaking up, and provide examples of practical, evidence-based tools to help organizations support and encourage all members of the health care team to speak up.
