Articles and reports

/Articles and reports

The Blame Game by Steven Shorrock

In this article Steven Shorrock talks about the Blame Game and Just Culture.  He refers to the recent incident at the Oscars where the wrong winner was read out. Please click here to read […]

External review of ‘Never Events’ that occurred at Oxford Hospitals NHS Trust

Professor Brian Toft OBE was called upon to investigate a review on ‘Never Events’ that occurred at Oxford Hospitals NHS Trust between September 2013 and March 2015.  His role was to comment on the quality, […]

By |28th January, 2016|Articles and reports|0 Comments

How culture change could be achieved in the NHS – Occupational Psychology Report launched

The practical steps required to implement culture change in the NHS is the subject of a new report launched today, Thursday 6th November 2014, by the British Psychological Society’s (BPS) Division of Occupational Psychology (DOP) (details […]

By |6th November, 2014|Resources, Articles and reports|0 Comments

Independent safety investigation needed in the NHS *paper now available here*

The NHS should follow the lead of aviation and other safety-critical industries and establish an independent safety investigation agency, according to a paper published today by the Journal of the Royal Society of Medicine (*now direct access […]

By |31st October, 2014|Resources, Articles and reports|0 Comments

A Roadmap for Further Embedding Human Factors in the NHS

During 2014 a team of CHFG supporters worked with Helen Hughes from the Parliamentary and Health Service Ombudsman (seconded to NHS England) to identify a “road map” for the further embedding of human factors and […]

By |17th September, 2014|Articles and reports, News|0 Comments

A Model of Organisational Dysfunction in the NHS

This  conceptual paper, by Rachael Pope and Bernard Burnes, was published in 2013 in the Journal of Health Organization and Management,  Vol. 27 No. 6

It aims to explore “the reasons for the sometimes seemingly irrational and dysfunctional […]

Human factors and ergonomics as a patient safety practice

‘Human factors and ergonomics as a patient safety practice’, by Pascale Carayon, Anping Xie and Sarah Kianfar has recently been published by the Quality Safety, BMJ

Background Human factors and ergonomics (HFE) […]

By |18th February, 2014|Resources, Articles and reports|0 Comments

Turning Healthcare in to a High Reliability Industry

Memorial Hermann Shares 5 Steps

High reliability industries are everywhere; most people just don’t realize it — they range from amusement parks and zoos to oil drilling rigs, air traffic control and nuclear  submarines. High reliability is […]

By |7th February, 2014|Resources, Articles and reports|0 Comments

The Road Less Travelled – My Human Factors Journey

The importance of understanding human factors in the healthcare setting didn’t really hit me until my first day on the ward as a newly qualified registered nurse. Despite the previous three years of clinical training, […]

By |14th January, 2014|Resources, Editorials, Articles and reports|0 Comments

Accidental hypoglycaemia

Case Report

Accidental hypoglycaemia caused by an arterial flush drug error: a case report and contributory causes analysis

K. J. Gupta and T. M. Cook

Consultants, Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK


In 2008, […]

By |19th November, 2013|Resources, Articles and reports, Films and podcasts|0 Comments