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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.

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) SLIPPS is responding to the challenge to improve European patient safety competence and education. Errors, mishaps and misunderstandings are common and around 1 in 10 patients suffer avoidable harm (WHO 2014). The majority of adverse care episodes and near misses are preventable (Vlayen et al 2012) and such incidents impact upon patients, their families, health care organisations, staff and students.

'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.

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. Thomas L. Rodziewicz and John E. Hipskind explore medical error prevention in their book and conclude that: All providers (nurses, pharmacists, and physicians) must accept the inherent issues in their roles as healthcare workers that contribute to error-prone environments. Effective communication related to medical errors may foster autonomy and ultimately improve patient safety. Error reporting better serves patients and providers by mitigating their effects. Even the best clinicians make mistakes, and every practitioner should be encouraged to provide peer support to their colleagues after an adverse event occurs. Medical errors and near misses should be reported when they are discovered. Healthcare professionals are usually the first to notice a change in a patient's condition that suggests an adverse event. A cultural approach in which personal accountability results in long-term increased reporting reduces errors.

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. The patient was a 62-year-old man who underwent hip replacement surgery. During his surgery, incompatible prostheses made by different manufacturers were used. The error was identified when data from the procedure was recorded in the National Joint Registry several days later. The investigation centred on how the error occurred and what safety recommendations we could make to reduce the risk of a similar event happening again. The investigation focuses on hip replacement surgery but the findings are applicable to all orthopaedic joint replacements.

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.  Key recommendations All patients should be informed of the risks of general anaesthesia, including the possibility of AAGA, before their surgery. When consenting patients, practitioners should use a form of words that proportionately conveys the risks of AAGA. Consent for sedation should emphasise that the patient will be awake and therefore may have recall for at least parts of the procedure. Practitioners should identify certain situations or certain patient factors as constituting a higher risk for AAGA (including organisational factors such as overbooked or reorganised surgical lists) and highlight these at the WHO premeet/team brief. During induction of anaesthesia, practitioners should adhere to suitable dosing of intravenous agent, check anaesthetic effect before paralysis or instrumentation of the airway and maintain anaesthetic administration, including during transfer of patients (which is facilitated by a simple ABCDE checklist). If AAGA is suspected during maintenance (e.g., by patient movement), prompt attention should be paid to giving verbal reassurance to the patient, increasing analgesia, and deepening the level of anaesthesia. For cases requiring paralysis, the minimum dose of neuromuscular blocking drugs (NMBDs) that achieves sufficient neuromuscular blockade for surgery should be used, and the nerve stimulator is an essential monitor to titrate the dosing of NMBDs to this minimum. Where total intravenous anaesthesia (TIVA) is used, practitioners should adhere to the relevant recently published guidelines. At emergence, practitioners should first confirm that surgery is complete, then ensure NMBDs are adequately reversed before allowing the patient to regain consciousness. Practitioners should then manage the patient experience, particularly during awake extubation, by speaking to the patient. Cases of AAGA should be managed using the NAP5 pathway as a guide.

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.

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. The report documents concerns about the lack of a properly independent investigation system, unlike deaths in prison and police custody which are independently investigated pre-inquest, and the consistent failure by most NHS Trusts to ensure the meaningful involvement of families in investigations. Ultimately, it highlights the lack of effective public scrutiny of deaths in mental health detention that frustrates the ability of NHS organisations to learn and make fundamental changes to policy and practice to protect mental health in-patients and prevent further fatalities and argues for urgent change to policy and practice.

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.

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. The report comes after the Healthcare Safety Investigation Branch (HSIB) looked at the case of 75-year old Ann Midson, who was left taking two powerful blood-thinning medications after a mix-up at her local hospital where she was receiving treatment whilst suffering from incurable cancer. Ann sadly died from her cancer 18 days after being discharged and the error with her medication was only picked up three days before. This led to the HSIB investigation to question why this happened, even when the hospital had an ePMA system in place. The report highlights that many NHS trusts across England are taking up this technology as they reduce medication errors, but that incomplete use of e-systems could create further risks to patient safety. The investigation found that often all the functions of ePMA systems aren’t being used and that staff switch between using paper record and digital records, increasing the likelihood of crucial information being missed. Ann’s case also highlighted the routine lack of information sharing between NHS services, such as GP surgeries and pharmacies. She had been taking one blood-thinning medication on admission. This was stopped during her time at the hospital, but this message was not relayed to her local pharmacy and she continued to take both after leaving the hospital. The report also identifies that the availability of a seven-day hospital pharmacy service is crucial to support a digital system and pick up any errors quickly. The length of time it took in Ann’s case had a huge effect on both her and her family. Ann’s daughter said: “Not only were we grieving the loss of mum but also that she had to deal with the stress and upset of this towards the end of her life. She had to spend a lot of time within different parts of the NHS and all we ever wanted was for her to get the best possible care at every stage.

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.

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. About the authors Robert W. Proctor is a distinguished professor of Psychological Sciences at Purdue University. He is a fellow of the American Psychological Association, Association for Psychological Science, and the Human Factors and Ergonomics Society, and recipient of the Franklin V. Taylor Award for Outstanding Contributions in the Field of Applied Experimental/Engineering Psychology from Division 21 of the American Psychological Association in 2013. He is co-author of Stimulus-Response Compatibility: Data, Theory and Application, Skill Acquisition & Training, and co-editor of Handbook of Human Factors in Web Design. Trisha Van Zandt is a professor of Psychology at The Ohio State University. She is a member of the Society for Mathematical Psychology, of which she was President in 2006-2007, and the American Statistical Association. She has received multiple research grants from the National Science Foundation and the Presidential Early Career Award for Scientists and Engineers in 1997. She is co-author of review chapters "Designs for and Analyses of Response Time Experiments" in the Oxford Handbook of Quantitative Methods and "Mathematical Psychology" in the APA Handbook of Research Methods in Psychology.

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.

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. Building on its successful predecessors, the third edition of The Field Guide to Understanding ‘Human Error’ will help you understand a new way of dealing with a perceived 'human error' problem in your organisation. It will help you trace how your organisation juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at all levels of your organisation, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding 'Human Error' will help you understand: how to move beyond 'human error' how to understand accidents how to do better investigations how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organisation face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organisation.

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. and a pioneer in emerging risk.

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.

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. I started my career in a care of the elderly ward (geriatrics), which was exciting as my first job, and I felt that my time management needed to be worked on prior to me starting my career in what I knew at the time to be emergency nursing. I stayed in this area for a year, taking charge of the shift and also managing a bay of eight patients, which was the norm (or so I thought). After about 1 year, I thought about moving on, continuing to learn, and I started working in an intensive care unit (ICU). During my time in ICU, I made a drug error involving a controlled drug. Without going into too much detail, there was a lot of factors involved in this case and I was told I was going down the disciplinary route. This was a real low point for me and I felt like I really needed support, not only to come to terms with the error itself, but also support from a reflective side – what I can do, so this doesn’t happen again. I was a new band 5 nurse in the department with no previous ITU experience, with a new Band 6 and Band 7 leading the team which we were working with solidly. They chose not to suspend me, but keep me working without being able to complete medications. I continued to work as per rota, never taking a day off sick, etc. This continued for about 3 months unable to complete my job role to its full potential, and continuing the days and nights and the weekend shifts, along with personal issues of my own to contend with also. I thought at the time it was normal to feel like this post an error, but in hindsight, the support I received was not adequate. In fact, I would go as far as to say I didn’t get any support, other than the normal "are you okay" at the start of each shift. By the time the disciplinary happened, I was 'rock bottom', which is banded around a lot, but I didn’t see a way out, without my family and partner saying that I needed to get out, I don’t know what I would have done. Nevertheless, I left for new horizons, and changed my speciality. I went to A&E where I knew I wanted to be, with a great team, with great management and culture. However, one day I let them down. I completed a second drug error. This was involving an insulin/dextrose infusion for hyperkalaemia, which I mixed up for hyperglycaemia. This error rattled me again. I felt like I was going down that 'rabbit hole' yet again, becoming more and more anxious and needing extra support, more than ever. Fortunately, the patient was okay and was identified quickly. The error was serious and after talking to my manager, they suspended me from clinical duties whilst the investigation was occurring. This was absolutely devastating to me. I felt like I was just settled in my job, feeling more positive about my career that I love so much. Whilst the investigation was going on, I continued my non-clinical work, completing various tasks that would normally take an age to complete. This is where I fell in love with the non-clinical side of the department and continue to work in this area today. However, in contrast to the first incident, I was asked whether I was okay, but also followed up with regular 1:1 welfare meetings, and felt like my manager was actively supporting me. I also started a piece of work on preventing this incident happening again. I have now gone up the ladder in the same organisation, and continue to feel settled. However, this really put the importance of supporting people as one of the main priorities in my daily practice. It also put into context the real need for establishing and integrating a no blame culture and getting rid of the culture of fear. It is very easy to forget the mental health aspect. Patient safety is aimed at patients (quite rightly so), but I think somewhere in the mix, we forget about that individual who takes this home day in, day out. I understand that there is accountability and there is taking responsibility for your actions as per the Nursing & Midwifery Council (NMC) Code of Conduct. But I think we forget about humanity and the need for support and coming together when one of your team is 'down'. I can honestly say, without my team and my managers, I wouldn’t be the nurse I am today, and I am forever grateful. And those people who have done errors or know what this is like, maybe you’re going through this today; there is light at the end of the tunnel. I share my story with the upmost respect and apologies to the patients involved and also to my team!

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. 

Read the latest episode in a series of podcasts from the Clinical Human Factors Group giving tips from frontline staff working with Covid patients. Podcast 1 – Interview with Chris Frerk Podcast 2 – Interview with Mark Stacey Podcast 3 – Interview with Stephen Hearns Podcast 4 – Interview with Claire Cox

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.

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. Hospitals are environments where resources are concentrated for the purposes of delivering care at an industrial level. In the US, the shift towards a pay-for-performance ecosystem has motivated health systems to pursue initiatives like operational standardisation and mergers — both horizontal and vertical, with little to show in terms of improvements in quality of healthcare delivered. The job of the chief safety and quality officer in such an industrial environment is complicated and therefore difficult. Opportunities for leaders and staff to learn from safety events in hospitals are limited. Systems and leaders have tried to “process” and “workflow” (structured follow ups, root cause analyses, FMEA analyses, etc.) their way through the complex hospital environment using deterministic approaches that are best suited for mechanistic, rather than adaptive systems. Isn’t it time for us to see hospitals as the complex adaptable systems they are: environments where there is high outcome variability in the Zone of Complexity (Stacey, 1996); where staff respond to safety events in unpredictable ways? A complex adaptive system is one where a variety of actors with diverse skills, experience and knowledge follow simple rules of engagement to learn and innovate in unpredictable ways based on unit and system-level feedback loops and is one where people are densely interconnected by virtue of their varied roles in managing patients. Hospitals need solutions that can adapt to the complexity involved in safety event management practices, solutions that support the insights that actors need to innovate and collaborate while supporting the basic principles of managing in a complex adaptive system environment that is a hospital: They should allow safety event management practices to evolve over time by creating simple frameworks rather than prescriptive workflows for activities, such as structured follow-up, and cause analyses initiatives. They should provide safety teams the ability and the collaboration spaces necessary for innovative ideas to emerge at the local and system levels. They should have the ability to support processes that generate variation while simultaneously helping stem the proliferation of ineffective or inefficient ideas related to improving patient safety within the system.

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. 

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.