Jump to content

Search the hub

Showing results for tags 'Latent error'.

More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous


  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
    • Questions around Government governance
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient Safety Partners
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training & education
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous


  • News

Find results in...

Find results that contain...

Date Created

  • Start

Last updated

  • Start

Filter by number of...


  • Start



First name

Last name


Join a private group (if appropriate)

About me



Found 24 results
  1. Content Article
    Hospitals are complex adaptive systems. They are industrial environments where it isn't always possible to expect predictable responses to inputs. Patient safety management practices need to adapt to align with the environment in which events occur. It is time to reimagine safety event reporting and management solutions that guide, not prescribe, investigations and improvement actions.
  2. Content Article
    Simulations are routinely used to identify latent safety threats. This article describes the classification of 1,318 latent safety threats identified from 232 simulations. Researchers were then able to issue site-specific and organisation-wide standardised dashboards and summaries, thus allowing for local and systemwide improvements.
  3. Community Post
    How can nurses spot error traps and near misses so that Trusts can learn, respond and take action to prevent unsafe care? What are the barriers to nurses using their insight and where is the good practice that we can share? Any ideas, anyone?
  4. Content Article
    Learning from mistakes generally is considered the upside to failure. But in healthcare, where staff members regularly face stressors and systemic issues that impede a strong culture of safety, creating that standard can be difficult.  To understand why medical mistakes and care complications occur repeatedly Becker's spoke with Patricia McGaffigan, vice president of safety programmes for the Institute for Healthcare Improvement. Ms. McGaffigan outlined three factors that contribute to repeat medical errors, care complications or lost progress on quality improvement initiatives: A "whack-a-mole" approach to safety. Lack of focus on systemwide changes. Unhealthy or unsafe work environments. 
  5. Content Article
    Medical errors are a serious public health problem and a leading cause of death in the United States. It is a difficult problem as it is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimises the chances of a recurrent event. By recognising untoward events occur, learning from them, and working toward preventing them, patient safety can be improved.  Part of the solution is to maintain a culture that works toward recognising safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organisations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers.
  6. Content Article
    SLIPPS (Shared LearnIng from Practice to improve Patient Safety) is a 3 year Erasmus+ funded Patient Safety education project. The project will: draw on the real experiences of health/social care students in practice placements  utilise these experiences as the basis for a range of educational resources set up an international patient safety education network build an international open access virtual learning centre for international, multi-professional learning about patient safety Who is involved? 7 Higher Education institutions 5 Health and/or social care providers 5 European countries (UK, Finland, Spain, Italy and Norway)
  7. Content Article
    The objective of this systematic review from Kuitunen et al., in the Journal of Patient Safety, was to identify systemic defenses (such as barcode scanning) to confirm drug and patient identity, clinical decision systems, and smart infusion pumps) to prevent in-hospital intravenous (IV) medication errors. Of the 46 included studies, most discussed systemic defenses related to drug administration; fewer discussed defenses during prescribing, preparation, treatment monitoring and dispensing. Closed loop medication management and smart pumps were the most common systemic defenses examined in the included studies The authors identify a need for further studies exploring the effectiveness of different combinations of systemic defenses.
  8. Content Article
    The authors of this paper, published in Clinica Chimica Acta, argue that in the current health care organisational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety: We need to move from looking at errors as individual failures to realising they are caused by system failures We must move from a punitive environment to a just culture We move from secrecy to transparency Care changes from being provider (doctors) centred to being patient-centred We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, inter-professional teamwork Accountability is universal and reciprocal, not top-down.
  9. Content Article
    A recent report from the Healthcare Safety Investigations Branch, Investigation into electronic prescribing and medicines administration systems and safe discharge, highlighted the fact that poorly implemented ePMA (electronic prescribing and medicines administration) systems can result in potentially fatal medication errors. The report focused on the death of 75 year-old Mrs Ann Midson, following a medication error.  In this podcast interview, Pharmacy in Practice speaks to Scott Hislop and Helen Jones, two of the investigators, to discuss the series of events that ultimately culminated in the sad passing of Mrs Ann Midson.
  10. Content Article
    When Julie Bailey took her mother, Bella, into Mid Staffs Hospital in September 2007 she had no idea that her life was about to change forever. Over the next eight weeks she would witness such shocking neglect and abuse of elderly, vulnerable patients that the memories would haunt her for the rest of her life. And over the next five years she would uncover a culture of deceit and denial going right to the top of the NHS. From Ward to Whitehall is the story of Julie s fight for the truth to be uncovered about the deadly failings at Mid Staffs Hospital and her struggle to ensure that the tragedy would never be repeated.
  11. Content Article
    Recently, there have been a number of advances in technology, including in mobile devices, globalization of companies, display technologies and healthcare, all of which require significant input and evaluation from human factors specialists. Accordingly, this textbook has been completely updated, with some chapters folded into other chapters and new chapters added where needed. The text continues to fill the need for a textbook that bridges the gap between the conceptual and empirical foundations of the field.
  12. Content Article
    This edited book concerns the real practice of human factors and ergonomics (HF/E), conveying the perspectives and experiences of practitioners and other stakeholders in a variety of industrial sectors, organisational settings and working contexts. 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 HF/E: improved system performance and human wellbeing.
  13. Content Article
    When faced with a ‘human error’ problem, you may be tempted to ask 'Why didn’t these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable people in it.
  14. Content Article
    Healthcare is advancing at a quicker rate than ever before. With the introduction of Artificial Intelligence (AI), you can now get a cancerous mole diagnosed with a mobile device. The reliance on technology has never so great. With technology predicted to replace as much as 80 per cent of a physician’s everyday routine, we must question what the new threats posed to patient safety are? This article, written by CFC Underwriting, explains some of the pitfalls of the new technology. CFC is a specialist insurance provider.
  15. Content Article
    This is the first in a series of blog posts by Suzette Woodward around implementing patient safety. Part one describes the growing sense of unease about the way we do safety in healthcare and how we can do it differently. It describes the dominant approach to patient safety in healthcare we use today – which has been coined by some as Safety I.
  16. Content Article
    This is my story of how one bad experience can lead to another. We talk a lot about patients and their safety (quite rightly so) but very rarely do we hear about the healthcare professional who is going through turmoil and their mental health. This is my story.
  17. Content Article
    'When problems occur we hunt for a single root cause, that one broken piece or person to hold accountable. Our analyses of complex system breakdowns remains linear, componential and reductive.' This is evident in healthcare. Barry O’Reilly is a business advisor, entrepreneur and author who has pioneered the intersection of business model innovation, product development, organisational design and culture transformation. In this blog he discusses the 'drift into failure', i.e. we had the warning signs but accepted them as the norm.
  18. Content Article
    This report is the Healthcare Safety Investigation Branch (HSIB) first complete investigation which relates to the implantation of the wrong prostheses (artificial body parts) during joint replacement surgery — a surgical never event. A never event is a serious incident that is entirely preventable.
  19. Content Article
    The 5th National Audit Project (or NAP5) of the Royal College of Anaesthetists and Association of Anaesthetists was the largest ever study into accidental awareness during general anaesthesia (AAGA). Numerous publications emerged from the project and whereas a comprehensive list of 64 recommendations were made, the full report and associated publications were primarily academic outputs not accessible to all practitioners as a day-to-day ready reference, nor did they provide practical recommendations that individuals could use in their daily practice. The purpose of this publication is to distil and interpret the findings of the 5th National Audit Project into actions that individuals (and organisations) can follow to reduce the risk of accidental awareness. 
  20. Content Article
    The struggle to perform well is universal, but nowhere is this drive to do better more important than in medicine. In his book, Atul Gawande explores how doctors strive to close the gap between best intentions and best performance in the face of obstacles that sometimes seem insurmountable. His vivid stories take us to battlefield surgical tents in Iraq, to a polio outbreak in India and to malpractice courtrooms around the country. He discusses the ethical dilemmas of doctors' participation in lethal injections, examines the influence of money on modern medicine and recounts the astoundingly contentious history of hand-washing. Finally, he gives a brutally honest insight into life as a practising surgeon. Unflinching but compassionate, Gawande's investigation into medical professionals and their progression from good to great provides a detailed blueprint for success that can be used by everyone.
  21. Content Article
    As part of Patient Safety Awareness Week 2020, the Royal College of Pathologists speak to Professor Peter Johnston about preventing patient harm in laboratory settings.
  22. Content Article
    Using human factors science increases the likelihood of obtaining well-designed and easy to use products to deliver safe patient care. Poor designs, by contrast, can cause unintended harm to patients. This guide, developed by the Clinical Human Factors Group, is to help staff working in procurement or with medical devices and equipment, to use human factors to specify and select the best and safest products to use in healthcare. This is important because conformity with regulations and standards does not always guarantee safe outcomes when products are used in practice. This guide is particularly relevant to medical devices but can be used for other healthcare products. 
  23. Content Article
    Read the latest episode in a series of podcasts from the Clinical Human Factors Group giving tips from frontline staff working with Covid patients.
  24. Content Article
    INQUEST's groundbreaking evidence-based report is based on our work with families of those who have died in mental health settings and related policy work. It identifies three key themes:  1. The number of deaths and issues relating to their reporting and monitoring. 2. The lack of an independent system of pre-inquest investigation as compared to other deaths in detention. 3. The lack of a robust mechanism for ensuring post-death accountability and learning.
  • Create New...