Considering human factors and developing systems-thinking behaviours to ensure patient safety

Considering human factors and developing systems-thinking behaviours to ensure patient safet

More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England?

What prevents the delivery of effective, high quality, and safe healthcare in the National Health Service (NHS) in England? This paper presents 760 challenges which 330 NHS staff reported as preventing the delivery of effective, high quality and safe care. Some problems have been known for over 25 years (staff shortages, finance and patient complexity) but other challenges raise questions about the commitment of the NHS to patient and staff safety. For example Organisational Culture leading to ‘stifling bureaucracy’, ‘odds stacked against smooth […] working’ and Workload resulting in ‘firefighting daily’ and ‘perpetual crisis mode’. The role of Human Factors/Ergonomics professional input (engagement with safety scientists) is discussed in the context of success stories and examples of Human Factors Integration from other safety critical industries (Defence, Nuclear and Rail)

Влияние марксизма на теорию и практику трудового воспитания А. С. Макаренко

<div><p>ABSTRACT</p><p><b>Background:</b> The systems-based management of laboratory test ordering and results handling is a known source of error in primary care settings worldwide. The consequences are wide-ranging for patients (e.g. avoidable harm or poor care experience), general practitioners (e.g. delayed clinical decision making and potential medico-legal implications) and the primary care organization (e.g. increased allocation of resources to problem-solve and dealing with complaints). Guidance is required to assist care teams to minimize associated risks and improve patient safety.</p><p><b>Objective:</b> To identify, develop and build expert consensus on ‘good practice’ guidance statements to inform the implementation of safe systems for ordering laboratory tests and managing results in European primary care settings.</p><p><b>Methods:</b> Mixed methods studies were undertaken in the UK and Ireland, and the findings were triangulated to develop ‘good practice’ statements. Expert consensus was then sought on the findings at the wider European level via a Delphi group meeting during 2013.</p><p><b>Results:</b> We based consensus on 10 safety domains and developed 77 related ‘good practice’ statements (≥ 80% agreement levels) judged to be essential to creating safety and minimizing risks in laboratory test ordering and subsequent results handling systems in international primary care.</p><p><b>Conclusion:</b> Guidance was developed for improving patient safety in this important area of primary care practice. We need to consider how this guidance can be made accessible to frontline care teams, utilized by clinical educators and improvement advisers, implemented by decision makers and evaluated to determine acceptability, feasibility and impacts on patient safety.</p></div

Why is the NHS still harming patients? Taking a professional approach to patient safety for COVID-19 and beyond

Why is the NHS still harming patients? Taking a professional approach to patient safety for COVID-19 and beyon

Additional file 1: of Assessing safety climate in acute hospital settings: a systematic review of the adequacy of the psychometric properties of survey measurement tools

Search Strategy. Electronic databases search strategy. Tools Descriptions. Descriptions of the five tools examined in the systematic review. (DOCX 42 kb

Exploring Patient Safety in Maternity and Midwifery Care

This is the first of a series of four co-written papers for the Advancing Practice series. In this paper we briefly explore the relevance of patient safety within the context of NHS Resolution’s publication The second report: The evolution of the Early Notification Scheme.1 In this series, we hope to support Midwives’ understanding of the current maternity safety landscape.</p

What are Human Factors and Ergonomics?

This is the second of four co-written papers for the Advancing Practice series. In our first paper weexplored patient safety in maternity and midwifery care. Here, we discuss ‘Human Factors and Ergonomics’ within healthcare, maternity, and midwifery.  The reflection points throughout this Advancing Practice piece are adapted from the NHS Education for Scotland’s “Safety Culture Discussion Cards.1 In this paper, we hope to support Midwives’ understanding of the current maternity safety landscape via a Human Factors perspective.</p

Advancing Practice 3: Changing worldviews: How can a Systems Approach Support Midwifery and Maternity care?

This is the third of four co-written papers for the Advancing Practice series. In our first paper we explored patient safety in maternity and midwifery care. Next, we discussed ‘Human Factors and Ergonomics’ within healthcare. Here we discuss healthcare systems and explore the “systems approach” in relation to recent developments in national patient safety? strategy. The reflection points throughout this Advancing Practice piece are adapted from the NHS Education for Scotland’s Safety Culture Discussion Cards (ref). In this series, we hope to support midwives’ understanding of the current maternity safety landscape.</p

Frontiers in human factors: embedding specialists in multi-disciplinary efforts to improve healthcare

Despite the application of a huge range of human factors (HF) principles in a growing range of care contexts, there is much more that could be done to realize this expertise for patient benefit, staff wellbeing and organizational performance. Healthcare has struggled to embrace systems safety approaches, mis-applied or misinterpreted others, and has stuck to a range of outdated and potentially counter-productive myths even has safety science has developed. One consequence of these persistent misunderstandings is that few opportunities exist in clinical settings for qualified HF professionals. Instead, HF has been applied by clinicians and others, to highly variable degrees – sometimes great success, but frequently in limited and sometimes counter-productive ways. Meanwhile, HF professionals have struggled to make a meaningful impact on frontline care and have had little career structure or support. However, In the last few years, embedded clinical HF practitioners have begun to have considerable success that are now being supported and amplified by professional networks. The recent COVID-19 experiences confirm this. Closer collaboration between healthcare and HF professionals will result in significant and ultimately beneficial changes to both professions and to clinical care

Ergonomics to support the Covid-19 response

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