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Found 500 results
  1. Content Article
    More information about "Top 10 priorities for patient safety in surgery (Royal College of Surgeons of Edinburgh)"
    We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 priorities for patient safety in surgery. This resource is for surgeons, anaesthetists and other healthcare professionals who work in surgery and contains links to useful tools and further reading. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 patient safety tips for surgical trainees 1. Foster a culture of safety through design Establish a psychologically safe environment, through design, where staff feel empowered to speak up without fear of blame. Promote a Just Culture, balancing personal accountability with systems-based learning from adverse events and near misses. Actively encourage multidisciplinary teamwork and peer support, with support from senior leadership, to enhance safety and well-being. Other useful RCSEd resources: Anti bullying and undermining campaign Sexual misconduct in surgery - Lets remove it campaign Addressing conflict in surgical teams workshop 2. Implement team-based quality and safety reviews Use team-based quality reviews (TBQRs) and structured case analysis to learn from everyday work, incidents and near misses. Translate findings into sustainable improvement initiatives that enhance both patient outcomes and staff experience. Foster a culture of collective learning, ensuring safety insights lead to actionable change. Other useful RCSEd resources: Making sense of mistakes workshop 3. Apply Human Factors principles and systems thinking principles in surgical and clinical practice Design resilient systems that mitigate work and cognitive overload and enhance performance reliability. Use TBQR principles to support this. Standardise workflows, optimise usability of IT systems and medical devices, and integrate cognitive aids (e.g. WHO Safe Surgery Checklists, prompts). Ensure governance processes support safe, efficient and user-friendly surgical environments. Other useful RCSEd resources: Systems safety on surgical ward rounds Improving the working environment for safe surgical care Improving safety out of hours 4. Enhance communication & handover processes Implement structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation) to improve clarity and effective decision-making. Optimise handover processes with digital tools, checklists and standardised documentation. Reinforce closed-loop communication, ensuring critical information is confirmed and acted upon. Other useful RCSEd resources: Consultation Skills that matter for Surgeon (COSMOS) 5. Strengthen leadership & accountability in patient safety Senior leaders must visibly support safety initiatives and proactively engage frontline staff in decision-making. Embed structured mechanisms for raising concerns, including TBQR, safety huddles and escalation pathways. Ensure staff have access to training, resources and protected time for safety and quality improvement work. 6. Minimise medication errors in surgery Implement electronic prescribing and technology assisted medication administration to mitigate errors. Enforce double-check procedures for high-risk medications and standardised drug labelling. Improve intra and peri-operative medication safety with clear labelling, colour-coded syringes and real-time verification. 7. Improve early recognition & response to deterioration Appropriate regular training of teams on processes and pathways supported by good design of staff rota ensuring adequate staffing levels. Implement early warning scores and establish rapid response pathways for deteriorating patients. Standardise post-operative surveillance strategies, ensuring timely escalation and intervention. Other useful RCSEd resources: Recognition and prevention of deterioration and injury (RAPID) course for training in recognising critically ill patients 8. Engage patients & families as safety partners Encourage shared decision-making to align treatment plans with patient expectations and values. Provide clear communication on risks, benefits and post-operative care, using tools like patient safety checklists and focus on informed consent processes. Actively involve patients and families in safety and quality initiatives and hospital discharge planning. Other useful RCSEd resources: Patient/carer/families resources and information Informed consent courses (ICoNS) 9. Standardise, simplify & optimise surgical processes Reduce unnecessary complexity in clinical workflows, making processes intuitive, efficient and reliable. Co-design standard operating procedures, policies and pathways with frontline teams to minimise variation. Implement automation and digital solutions where feasible to streamline repetitive tasks. Other useful RCSEd resources: NOTSS (Non Operative Technical Skills for Surgery) courses for surgeons DenTS courses for dentists 10. Promote continuous learning & simulation-based training Conduct regular simulation training for critical scenarios (e.g. sepsis, airway emergencies, human factors). Use insights from TBQR and incident reviews to target training needs and refine clinical practice. Ensure ongoing professional development by providing staff with time, resources, incentives and institutional support for learning. Other useful RCSEd resources: Education pages Edinburgh Surgery OnLine MSc in Patient Safety and Clinical Human Factors
  2. Content Article
    Errors are the result of actions that fail to generate the intended outcomes. They are categorised according to the cognitive processes involved towards the goal of the action and according to whether they are related to planning or execution of the activity. This article in SKYbrary discusses the types of human error.
  3. Content Article
    When big problems in the NHS are highlighted by comparing it to other organisations, the service often reacts in a hostile and dismissive manner. But these complaints usually completely miss the point of the comparison. Recently Diane Coyle suggested the NHS could learn from the way a Formula 1 racing team operates, but it was met with unwarranted hostile reaction by some commentators. In this HSJ article, Steve Black explores how resistance to outside comparisons hides deep flaws in NHS systems, priorities, and data use.
  4. Content Article
    Anaesthetic emergencies, though infrequent, pose a significant threat to patient safety. Simulation-based training offers participants the opportunity to immerse themselves in safe, realistic clinical scenarios, allowing them to hone their skills without risking patient harm. For the educator, the challenge lies in balancing the vast array of emergencies to be taught with limited resources available. This study explored whether focusing on transferable skills, specifically human factors, can improve confidence in managing these emergencies.
  5. Content Article
    In this LinkedIn post, Helen Vosper highlights the new Human Factors for patient safety course at Aberdeen University.
  6. News Article
    Despite ongoing efforts to improve patient safety, it’s estimated that at least 1 in 20 patients still experience medical mistakes in the health care system. One of the most common categories of mistakes is medication errors, where for one reason or another, a patient is given either the wrong dose of a drug or the wrong drug altogether. In the US, these errors injure approximately 1.3 million people a year and result in one death each day, according to the World Health Organization. In response, many hospitals have introduced guardrails, ranging from colour coding schemes that make it easier to differentiate between similarly named drugs, to barcode scanners that verify that the correct medicine has been given to the correct patient. Despite these attempts, medication mistakes still occur with alarming regularity. Dr Kelly Michaelsen, an assistant professor of anaesthesiology and pain medicine at the University of Washington wondered whether emerging technologies could help. As both a medical professional and a trained engineer, it struck her that spotting an error about to be made, and alerting the anaesthesiologists in real time, should be within the capabilities of AI. “I was like, ‘This seems like something that shouldn’t be too hard for AI to do,’” she said. “Ninety-nine percent of the medications we use are these same 10-20 drugs, and so my idea was that we could train an AI to recognize them and act as a second set of eyes.” Michaelsen focused on vial swap errors, which account for around 20% of all medication mistakes. All injectable drugs come in labelled vials, which are then transferred to a labelled syringe on a medication cart in the operating room. But in some cases, someone selects the wrong vial, or the syringe is labelled incorrectly, and the patient is injected with the wrong drug. Michaelsen thought such tragedies could be prevented through “smart eyewear” — adding an AI-powered wearable camera to the protective eyeglasses worn by all staff during operations. Working with her colleagues in the University of Washington computer science department, she designed a system that can scan the immediate environment for syringe and vial labels, read them and detect whether they match up. In a study published late last year, Michaelsen reported that the device detected vial swap errors with 99.6% accuracy. All that’s left is to decide the best way for warning messages to be relayed and it could be ready for real-world use, pending Food and Drug Administration clearance. Read full story Source: NBC News, 25 May 2025
  7. Content Article
    Large Language Models (LLMs) are transforming the way in which people interact with artificial intelligence. This study explores how safety professionals might use LLMs for a FRAM analysis. The authors use interactive prompting with Google Bard / Gemini and ChatGPT to do a FRAM analysis on examples from healthcare and aviation. The exploratory findings suggest that LLMs afford safety analysts the opportunity to enhance the FRAM analysis by facilitating initial model generation and offering different perspectives. Responsible and effective utilisation of LLMs requires careful consideration of their limitations as well as their abilities. Human expertise is crucial both with regards to validating the output of the LLM as well as in developing meaningful interactive prompting strategies to take advantage of LLM capabilities such as self-critiquing from different perspectives. Further research is required on effective prompting strategies, and to address ethical concerns.
  8. Content Article
    If you have up to an hour to spare, these 'micro credentials' are great for topping up your learning. The Chartered Institute of Ergonomics & Human Factors (CIEHF) online bitesize modules will offer you short, focused and easily digestible content. Delivered through CIEHF's online learning platform, they'll provide the flexibility to learn at your own pace, to your schedule and from wherever you choose. Whether you're a professional seeking to improve workplace ergonomics or a curious learner eager to understand how humans interact with their surroundings, these modules are designed to inspire you by providing real-world examples, case studies and best practice that can be applied across many sectors. You'll get insights into identifying and addressing human factors challenges, ultimately contributing to improved safety, efficiency and overall wellbeing.
  9. Content Article
    High-reliability organizations (HROs) operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. Interventions are designed to change thinking about patient safety and system performance through distinct HRO principles. The purpose of this review was to determine the effectiveness of implementing HRO principles on patient safety outcomes.
  10. Content Article
    This study looked at the factors influencing nurses' recognition and response to patient deterioration. Seventeen studies were reviewed and appraised. Recognising patient deterioration was encapsulated in four themes: (1) assessing the patient; (2) knowing the patient; (3) education and (4) environmental factors. Responding to patient deterioration was encapsulated in three themes; (1) non-technical skills; (2) access to support and (3) negative emotional responses. The study concluded that issues involved in timely recognition of and response to clinical deterioration remain complex, yet patient safety relies on nurses’ timely assessments and actions.
  11. Event
    Aimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process, and safety. The conference delves into integrating human factors into healthcare systems and processes, clinical decision making, healthcare system design, quality of patient experience, medication safety, and workload, fatigue, and stress management. Throughout the day there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/a-practical-guide-to-human-factors-in-healthcare or email [email protected] Complementary free places for hub members. Please use code hcuk00psl when booking
  12. Content Article
    The introduction of the Patient Safety Incident Response Framework (PSIRF) has removed traditional oversight targets, requiring practitioners to take a flexible, improvement-focused approach. While this shift is intended to improve patient safety, it has also created uncertainty for those in oversight roles, who must navigate new responsibilities without the comfort of prescriptive performance metrics. This article provides practical guidance on PSIRF oversight and introduces the Self-Assessment Framework for Event Response (SAFER) Oversight tool. The article outlines the mindset and functions needed to support effective, improvement-focused governance. It explores three aspects of oversight mindset: systems thinking, improvement focus, and compassion - as well as three oversight functions: demonstrating and assuring improvement, supporting and collaborating, and facilitating learning across the system. By clarifying the role of oversight within PSIRF, this article aims to reduce uncertainty and support practitioners in delivering meaningful patient safety improvements.
  13. News Article
    Patients’ lives are being put at risk by poor communication from healthcare professionals in hospitals worldwide, according to new research. The analysis included 46 studies, published between 2013 and 2024, involving over 67,000 patients across Europe, North and South America, Asia and Australia. And the findings are alarming. The authors discovered that poor communication was the sole cause of patient-safety incidents in over one in ten cases and contributed to causing incidents in one in four cases. These aren’t just statistics, they represent real people harmed by preventable errors. In one documented case, a doctor accidentally shut off a patient’s Amiodarone drip (a drug to treat heart arrhythmias) while silencing a beeping pump. The doctor failed to tell the nurse, and the patient’s heart rate spiked dangerously. In another example, a patient died after a nurse failed to tell a surgeon that the patient was experiencing abdominal pains following surgery and had a low red blood cell count – clear indicators of internal bleeding. The patient later died from a haemorrhage that could have been prevented with adequate communication. These findings confirm what many healthcare professionals have long suspected: communication breakdowns directly threaten patient safety. What’s particularly concerning is that these incidents cut across different healthcare systems worldwide. Read full story Source: The Conversation. 28 April 2025
  14. Content Article
    Poor communication in healthcare increases the risk for patient safety incidents. However, there is no up-to-date synthesis of these data. The aim of this study was to synthesise studies investigating how poor communication between healthcare practitioners and patients (and between different groups of practitioners) affects patient safety. The study found that poor communication is a major cause of patient safety incidents. Research is needed to develop effective interventions and to learn more about how poor communication leads to patient safety incidents.
  15. Content Article
    It is important that dentistry looks beyond technical/clinical skills as a marker of success and that non-technical skills have equal, if not additional credibility. This means capitalising on psychological safety, communication, leadership, teamwork, situation awareness, decision-making, and cooperation.  Human Factors in Dentistry are considered through the lens of members of the dental and oral health teams being able to work safely and to the best of their ability, ensuring that safe treatments and care are provided. Find out more on Human Factors in Dentistry website.
  16. Content Article
    More information about "Speaking up for patient safety: Beatrice Fraenkel in conversation with Peter Duffy and Helen Hughes"
    In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, Beatrice Fraenkel, ergonomist and Non Executive Director at Stockport NHS Foundation Trust discusses the importance of understanding the issues that lead to poor culture and harm in healthcare organisations. She describes the Board's radical approach to establishing a Just Culture during her time as Chair of Mersey Care NHS Foundation Trust and the huge investment needed to build trust between healthcare staff and their employers. She also talks with Peter and Helen about the importance of understanding the needs, views and emotions of people in the wider community that each trust serves. They discuss the universal impact of fear and anxiety on human behaviour and the need to ensure lessons are really understood before attempting to put solutions in place to tackle issues, on any scale. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series
  17. Content Article
    Patient safety, patient and family experience, and staff wellbeing are the joint responsibility of anyone working within health and social care. An understanding of how Humans Factors and Ergonomics can improve our interactions with systems and processes can often lead to improved patient and staff outcomes. If you are responsible for implementing Human Factors and Ergonomics programmes within a health and social care setting – or if you just want to understand more about how the principles of human factors might apply to your role – this practical introduction will help you navigate your way around Human Factors and Ergonomics approaches within the healthcare setting. Key features include: Aligned to the Chartered Institute of Ergonomics and Human Factors professional competencies, this book shows how these can be framed within real-life practice. Packed with case studies and helpful tips you can use in your day-to-day practice. Clear structure showing the different levels of a system with specific chapters on organisation, people, equipment and environment. Fully illustrated to facilitate your learning. The authors discuss the book in this interview with Class.
  18. Content Article
    More information about "Safety Talks Podcast: Human Factors in Healthcare - Culture, Communication, and Change (28 March 2025)"
    In this episode Dr Paul Grime, Chairman of the Safer Healthcare and Biosafety Network, is joined by Professor Peter Brennan, consultant surgeon and leading voice on Human Factors in healthcare. Together they explore how better understanding of Human Factors can improve staff and patient safety, reduce error, and shift culture away from blame. Drawing on insights from aviation, real-life NHS incidents, and Peter’s extensive research, this conversation tackles everything from toxic hierarchies and communication breakdowns to the power of kindness and just culture. Safety Talks is a podcast series as part of the Safety for All Campaign, launched to shine a light on the symbiotic relationship and benefits of integrating the approach to deliver healthcare worker safety and patient safety.
  19. Event
    This is a 6 hour CPD approved course, written, continuously developed and delivered by Rob Galloway. It evolved after he was involved in a patient’s death 16 years ago. This led to his “Damascus moment”, as he had a realisation that the traditional ways of looking at improving patients safety were not working and a new mindset was needed. The course is based on his 23 years of clinical experience and extensive work looking into the best ways to provide safer care and how best to implement the needed changes. The course has now been taken by over 3,000 people and is different in many ways to other human factors courses, in that it looks at things from a clinician’s perspective. As opposed to those in the airline industry who can decide to just not fly a plane if conditions are not ideal, his course is based on how to provide safer care in difficult circumstances where care must be provided whatever the situation is. The course is aimed to give attendees a basic understanding of human factors and the importance of changing the culture to bring about improvements in care. As well as the traditional aspects of human factors such as team working and communication skills, the course looks at how we can improve our decision making skills by reducing cognitive bias. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/human-factors-a-journey-in-improving-care-a-journey-in-improving-care or email [email protected] hub members receive a 20%. Email [email protected] for discount code.
  20. Event
    This course from Medled will: Introduce Human Factors For Healthcare; what is it and why does it matter? Ask we mean by ‘Systems Thinking’? Looking beyond the flawed concept of Human Error, utilising the SEIPS tool. Establish difference between simple, complicated and complex work, and how this might impact our approach to safety and performance. Look at different models of safety & risk across the spectrum of working practice; balancing the focus of rule based and adaptive working. Explore the impact of stress and cognitive load on decision making and how we can perform at our best under pressure. Discuss the key components of High Performing Teams, in particular the impact of Psychological Safety and how it can be developed. Provide a practical and tangible tool for addressing our physiological needs. Register
  21. Content Article
    Even as the healthcare system relies on this tapestry of inanimate resources, healthcare remains fundamentally human. It’s people who give and receive care and people who help ensure safety and quality. Yet humans can also misstep. When humans make errors, we ask why. Human factors engineers specialise in understanding how design of a system creates opportunities for human error. Their mission is to design work systems to support the work people need to accomplish. With that perspective, human error becomes an impetus to find weaknesses in the system so that safety and performance goals can be met.
  22. Event
    until
    The Institute for Healthcare Improvement (IHI) is excited to introduce the Certified Professional in Human Factors in Health Care (CPHFH) certification! This credential validates your expertise in applying human factors principles to improve patient safety and system performance. About the Certification: Human factors is a critical discipline that optimizes interactions between technology, environments, systems, and people to reduce risks in health care. Earning this certification showcases your commitment to safer, more efficient health care systems. Exam Availability: The certification exam will be available starting March 10, 2025, and will assess your knowledge through multiple-choice questions and real-world scenarios. Prepare for the Exam with this live webinar from IHI. Register
  23. Content Article
    The Wales Ergonomics and Safer Patients Alliance (WESPA) was formed in response to supporting the NHS during the COVID-19 pandemic. WESPA comprises early career and senior researchers from across Cardiff University (Business, Engineering, Mathematics, Medicine) with expertise in operations management, human factors and resilience engineering. We work closely with NHS professionals (clinicians, managers and executives) to model how the design of health services impact on staff and patient outcomes. WESPA's primary aim is to carry out applied research driven by clinical need by drawing upon research expertise from across Cardiff University to enable innovation and implementation of practices to improve patient safety in the NHS, by: Partnering with NHS organisations, and working directly with NHS staff, to identify improvement priorities, it will: - embed researchers-in-residence to analyse patient safety data and observe in clinical settings; - build capability to develop data infrastructures that promote timely organisational learning to inform service design, planning and management; - evaluate models of service delivery to identify where and how the service can be designed / redesigned to improve staff and patient outcomes. Leading engagement activities with key stakeholders – healthcare professionals, managers, executives, patients, services users and the public – to gain timely feedback on our research findings. Facilitating co-production activities in the NHS to maximise understanding of human factors influencing staff and patient outcomes. Engaging with the third sector and other organisations with the purpose of influencing policy and achieving impact in the NHS. Research Development and testing of methodological approaches to apply human factors theory, principles and tools in the NHS to understand and learn from complex socio-technical systems; Identification of opportunities for health systems improvement from analysis of routine patient safety data; and, Understanding complex systems by modelling and quantifying variability using the Functional Resonance Analysis Method (FRAM).
  24. Content Article
    There are many definitions of therapeutic empathy, which sometimes contradict each other. This leads to variation in how the concept is practiced, taught, and researched. This study analysed therapeutic empathy definitions, finding six common components: exploring understanding shared understanding feeling therapeutic action maintaining boundaries.
  25. Content Article
    Understanding human factors forms the basis for creating safer, more efficient healthcare systems. These two books from Perbinder Grewal equips readers with the knowledge to identify and address human limitations while leveraging strengths to design better workflows, environments, and interactions. It’s a must-read for healthcare professionals, policymakers, and patient safety advocates committed to fostering a culture of safety and innovation. Part 1: What are Human Factors? Part 2: Human Factrors & Patient Safety

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