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Found 25 results
  1. Content Article
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    The book aims to provide well-founded, practical guidance to those responsible for leading and implementing human factors programmes and interventions in health and social care. Chapter 2 objectives and learning outcomes: To describe, in simple terms, the concept of organisational culture, and specifically how safety culture relates to this. To recognise features of good safety culture. To define key concepts of proactive risk management. To briefly introduce the idea of safety management systems and safety cases. To introduce methods for assessing safety culture (and consider their strengths and weaknesses). Using a worked example, to introduce a tool for helping you to understand and strengthen safety culture in your own organisation.
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    As discussed at the network meeting as I can find the relevant folder, this is my simplified approach to SEIPS and open to suggested changes. It's nothing new per se (interactions), just the way I am approaching it at the moment which, as the new world order (PSIRF) moves into play I am trying to test it out in a meaningful way. I have included a simplified example. Regards Keith Understanding System Interactions.pdf
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    The book aims to provide well-founded, practical guidance to those responsible for leading and implementing human factors programmes and interventions in health and social care. It's structured around the different levels of a system, where practitioners might place their focus. For each level, the nature of issues that are frequently addressed is given, followed by a characterisation of available human factors methods and approaches. Then, a selection of representative and important human factors methods and approaches is described in detail using a practical example, helping guide practitioners through the many opportunities for human factors interventions and the wide range of methodological choice. Chapter 1 objectives and learning outcomes: To explain what human factors and the systems approach are. To understand what to look at within a healthcare work system. To be familiar with how human factors approaches improve system outcomes. To understand how human factors practitioners work.
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    This framework provides staff and medical staff with: a standardised methodology including a common analysis language; and standardised analysis tools for reviewing clinical adverse events and close calls. There are three methodologies described within this handbook that can be used to review clinical Adverse Events. These methodologies are designed to suit the scope of a clinical adverse event or multiple clinical adverse events, and provide flexibility for the user. The Concise method is commonly used for a succinct review of close calls or clinical adverse events that result in no, low, or moderate harm to the patient or may focus on a new event for which a Comprehensive analysis was recently completed. The concise method is generally used for reviews conducted by one or two individuals. The Comprehensive method is used for a thorough review of a single clinical adverse event and involves a team approach. The Aggregate method involves a thorough review of multiple clinical adverse events and/or quality assurance reviews. This method is resource intensive and involves a team approach.
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    Dear hub members We've a request to help from New South Wales. They and their RLDatix colleagues request: The public healthcare system in New South Wales (NSW), Australia is changing how we investigate health care incidents. We are aiming to add to our armoury of investigation methods for serious clinical incidents and would love to hear your suggestions. Like many health care settings worldwide, in NSW we have solely used Root Cause Analysis (RCA) for over 15 years. We are looking for alternate investigation methods to complement RCA. So we are putting the call out … Are there other serious incident investigation methods (other than RCAs) you would recommend? What’s been your experience with introducing and/or using these methods? Do you have learnings, data or resources that you could share? Do you have policy or procedure documents about specific methods? Any journal articles – health care or otherwise – that are must-reads? We've many resources on investigations on the hub and recent thinking in the UK and internationally that might be of value including: UK Parliamentary report - Investigating clinical incidents in the NHS and from that the creation of A Healthcare Safety Investigation Branch applying a wide range of methodologies in national learning investigations informed by ergonomics and human factors UK's NHS Improvement recent engagement on a new Serious Incident Framework (due to piloted in early 2020) Dr Helen Higham work with the AHSN team in Oxford to improve the quality of incident investigations Patient engagement in investigations Lessons to be learned from Inquiries into unsafe care and reflections on the quality of investigations Insights by leading investigators and resources written specifically for us by inclusion our Expert Topic Lead @MartinL Do check these out in this section of the hub https://www.pslhub.org/learn/investigations-risk-management-and-legal-issues/ Please add to this knowledge and give us your reflections. We'd be happy to start up specific discussions on topics of interest. Thank you all, Helen
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    Measurement of safety culture – a necessary suite in any Trust's safety measures? Well it seems not! This quick Twitter poll, along with observations from a number of large trusts and discussions at webinars, indicate that culture is not a measure many Trusts have got a handle on. The Patient Safety Incident Response Framework (PSIRF) implementation recommends in the pre-framework preparation that we are meant to be doing culture measurement for this important piece of work to land. With a range of tools around, it’s difficult to know how best to measure this sadly often pervasive and complex metric. There is MapSaF, Safety attitudes, Safety climate and Psychological safety measures. A useful booklet from The Health Foundation, 'Measuring Safety Culture', gives an overview of them all. The booklet also says that Trusts that are measuring culture are usually higher performing. There are a number of companies that provide fee paying links to administer it for you, but without resource it’s unlikely to be widely delivered. Some Trusts take a few of their staff survey questions to guide them rather than send out another survey to all their staff, but there are questions of validity around this practice. We also need to be able to break down results into areas, specialties and sites to measure for improvement. A validated tool to measure safety culture across organisations along with a platform to administer it is yet to become clear and we need a national solution to make its measurement standardised and possible. I'd love to hear if and how you are measuring safety culture and what tools you are using. Add your comments below.
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    This guide from the Health Foundation offers an explanation of some popular approaches used to improve quality, including where they have come from, their underlying principles and their efficacy and applicability within the healthcare arena. It also describes the factors that can help to ensure the successful use of these approaches and methods. to improve the quality of care processes, pathways and services. It is written for a general health care audience and will be most useful for those new to the field of quality improvement, or those wanting to be reminded of the key points.
  21. Content Article
    With a grant from The Doctors Company Foundation, the National Patient Safety Foundation convened a panel of subject matter experts and stakeholders to examine best practices around RCAs and develop guidelines to help health professionals standardize the process and improve the way they investigate medical errors, adverse events, and near misses. To improve the effectiveness and utility of these efforts, the Institute of Healthcare Improvement have concentrated on the ultimate objective: preventing future harm. Prevention requires actions to be taken, and so they have renamed the process Root Cause Analyses and Actions, or RCA2 (RCA “squared”) to emphasise this point. The purpose of this document is to ensure that efforts undertaken in performing RCA2 will result in the identification and implementation of sustainable systems-based improvements that make patient care safer in settings across the continuum of care. The approach is two-pronged: Identify methodologies and techniques that will lead to more effective and efficient RCA2. Provide tools to evaluate individual RCA2 reviews so that significant flaws can be identified and remediated to achieve the ultimate objective of improving patient safety. The purpose of an RCA2 review is to identify system vulnerabilities so that they can be eliminated or mitigated; the review is not to be used to focus on or address individual performance, since individual performance is a symptom of larger systems-based issues.
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