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Showing results for tags 'High reliability organisations'.
Found 38 results
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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 ArticleClive Flashman, Patient Safety Learning's Chief Digital Officer, shares his presentation slides from the Health Plus Care 2022 conference. The presentation slides include basic principles, how to involve the patient and public in design, key issues and Clive's ten top tips for digital health innovators.
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Content ArticleHigh reliability organisations are organisations that work in situations that have the potential for large-scale risk and harm, but which manage to balance effectiveness, efficiency and safety. They also minimise errors through teamwork, awareness of potential risk and constant improvement. This evidence scan collates empirical evidence about the characteristics of high reliability organisations and how these organisations develop within and outside healthcare. Key points The key characteristics of high reliability organisations include: complex high risk environments consequences of error would be serious collective mindfulness across organisation positive safety culture continuous improvement learning culture highly trained and well-rewarded staff creative ways to cope with errors regular checks redundancy of processes flexibility to deal with change.
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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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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 -
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 Article
In this video, Tim McDonald, Chief Patient Safety and Risk Officer at RLDatix, Paul Bowie, Programme Director (Safety & Improvement) at NHS Education for Scotland, and Helen Hughes, Chief Executive of Patient Safety Learning, talk about the relationship between human factors, high reliability in healthcare and patient safety. The key topics covered in this video are as follows: What is human factors/ergonomics and how does it relate to healthcare? (at 2 mins and 20 secs) What is the value of high reliability to healthcare? (at 9 mins and 20 secs) How can patient insights and contributions help to create more highly reliable organisations? (at 17 mins and 40 secs) Reflections on the impact of culture and barriers pose to increasing resilience and learning from safety. (at 20 mins and 45 secs) The role of ‘speaking up’ initiatives. (at 25 mins and 40 secs) Incident reporting and the importance of using the data from this effectively to improve patient safety. (at 31 mins) This is part of a joint series of blogs and video conversations exploring how we can improve patient safety through the application of principles of high reliability in healthcare, made collaboratively by Patient Safety Learning and RLDatix. Previous content in this series includes: Introductory blog: Improving patient safety through high reliability Video conversation: The importance of culture in achieving high reliability in healthcare Blog: The link between high reliability and positive reporting -
Content Article
In this video, Helen Hughes, Chief Executive of Patient Safety Learning, speaks to Phil Taylor, Chief Product Officer at RLDatix, about the importance of culture in achieving high reliability in healthcare. They discuss the impact of culture on incident reporting, examples of where safety culture is key to making improvements and consider what is needed to create the right safety culture. Play video The key topics covered in this video are as follows: Why is high-reliability important in addressing avoidable harm? (at 4 mins 25 secs). How culture impacts on the implementation and use of incident reporting solutions (at 8 mins). How incident reporting rates have changed during the pandemic (at 14 mins 25 secs). Positive reporting and learning from success (at 16 mins 25 secs). The role of Board members and non-executive directors understanding of incident reporting and risk management (at 22 mins 50 secs). Considering the importance of Board and non-executive director leadership and patient safety culture (at 26 mins 20 secs). Reflections on the role for patients reporting incidents (at 33 mins 35 secs). How healthcare can learn from other industries to create high reliability organisations and system (at 37 mins). Considering the complexity of healthcare and ensuring patient safety is seen as an issue for everyone involved (at 42 mins 40 secs). Read other content in this series Introductory blog: Improving patient safety through high reliability -
Content ArticleAlthough many initiatives have been implemented and great strides have been achieved in improving patient safety and reducing preventable medical errors, progress towards achieving "zero" avoidable harm continues to be slow. This video presentation will address common medical errors, their recognition, potential for harm and the psychological and financial costs. The concepts of human factors, system design and the high reliability organisation will be reviewed. New approaches in reducing harm and restoring trust will be described along with the opportunity for physician leadership. After watching the video, participants should be better prepared to: Acquire an understanding of the concept of a "medical error". Appreciate the safety movement. Understand the culture of safety. Illustrate real examples of adverse events and their sequelae. Identify a high reliability organisation.
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Content Article
IHI: Leadership guide to patient safety (2006)
PatientSafetyLearning Team posted an article in Clinical leadership
This US White Paper from the Institute of Healthcare Improvement shares the experience of senior leaders who have decided to address patient safety and quality as a strategic imperative within their organisations. It presents what can be done to make the dramatic changes that are necessary to ensure that patients are not harmed by the very care systems they trust will heal them. This paper presents eight steps that are recommended for leaders to follow to achieve patient safety and high reliability in their organisations. Step One: Address strategic priorities, culture and infrastructure Step Two: Engage key stakeholders Step Three: Communicate and build awareness Step Four: Establish, oversee and communicate system-level aims Step Five: Track/measure performance over time, strengthen analysis Step Six: Support staff and patients/families impacted by medical errors Step Seven: Align system-wide activities and incentives Step Eight: Redesign systems and improve reliability -
Content Article
Human error: models and management
Claire Cox posted an article in Improving patient safety
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. 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. -
Content ArticleA new MIT study identifies six systemic factors contributing to patient hazards in laboratory diagnostics tests. By viewing the diagnostic laboratory data ecosystem as an integrated system, MIT researchers have identified specific changes that can lead to safer behaviours for healthcare workers and healthier outcomes for patients.
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Content ArticleIn the UK and several other countries, including Norway, Australia and New Zealand, operators of safety-critical systems, such as nuclear power plants, public transportation systems and defence equipment, must develop a safety case to demonstrate that their systems are acceptably safe to operate. In these countries, the development, review and maintenance of safety cases are regulatory requirements. In the NHS in England, manufacturers of health information technology have been required to submit clinical safety cases since 2013. However, this is a domain with a narrow technological focus and limited organisational support. Mark Sujan and Ibrahim Habli discuss why they think safety cases would be a valuable addition to Safer Clinical Systems and patient safety practice?
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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. -
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 ArticleKrista Haugen is National Director of Patient Safety for US-based emergency and patient relocation services provider Global Medical Response. In this interview, she describes how her 25-year career as an emergency medicine nurse has influenced her approach to safety and patient care. She discusses her personal experience of being involved in an accident as an air-ambulance flight nurse, and how this caused her to look at safety and risk management from a systems perspective, focussing on building a just culture where safety is optimised through organisational reflection and learning.
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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 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 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.
