Safety clutter is the accumulation of safety procedures, documents, roles, and activities that are performed in the name of safety, but do not contribute to the safety of operations. Safety clutter is a problem because of the opportunity cost of ineffective activity, because clutter results in cynicism and ‘surface compliance,’ and because clutter can hamper innovation and get in the way of getting work done.
The authors of this paper identify three main mechanisms that generate clutter: duplication, generalisation, and over-specification of safety activities. These mechanisms in turn are
Small differences can lead to big changes which can escalate if carried out by many people on numerous occasions. Big changes in how autistic people with a learning disability access and experience healthcare can and should be informed by stakeholders, including the patient and their family.
Blair et al identified the following simple steps:
Take time to be with the person and their families to understand their lived experiences.
Pick up not only on what is said, but also what is not said, and avoid hurrying the interaction.
It is essential to remember that every interacti
What will I learn?
The report identifies 10 lessons to support providers and commissioners seeking to adopt this new approach:
Start by focusing on a specific population.
Involve primary care from the start.
Go where the energy is.
Spend time developing shared understanding of challenges.
Work through and thoroughly test assumptions about how activities will achieve results.
Find ways to learn from others and assess suitability of interventions.
Set up an ‘engine room’ for change.
Distribute decision-making roles.
Invest in workforce d
This resource is a key output from an NIHR-funded research project called INQUIRE: improving NHS quality using internet ratings and experiences. It turns the research findings and key lessons into a practical output. It is designed to help healthcare staff interpret and respond appropriately to online feedback and use it to improve healthcare delivery.
What can I learn?
Practical guidance and examples of best practice in the design of infusion devices
How design can be used to change and make safer the use of infusion devices in practice.
Principles that can be widely applied to the design of other technologies