Most errors and inefficiencies in patient care arise not from the solitary actions of individuals but from conflicting, incomplete, or sub-optimal systems of which they are a part and with which they interact. To improve […]
The Human Factors of Error Training
Using Effective Investigations to Improve Patient Safety
Bristol Medical Simulation Centre are running an innovative, interactive course incorporating Safety-I and Safety–II thinking into a practical approach to incident investigation.
Delivered by experienced […]
England’s 15 Patient Safety Collaboratives play an essential role in identifying and spreading safer care initiatives from within the NHS and industry, ensuring these are shared and implemented throughout the system.
They are based in the […]
- How does a consultant confirm all the initial steps in management have been completed?
- How does the doctor new to the emergency department learn how to deal with a condition they have never managed before?
- How does […]
In October the Department of Health set out a consultation seeking views on providing a ‘safe space’ in healthcare safety investigations, click here to view the consultation. The CHFG have been working with James Titcombe, […]
The implementation of the concept of “Just Culture” is now widely seen as key for further improvement of aviation safety through more and better reporting of aviation occurrences. An essential condition for establishing a “Just […]
Circle of Care is a model for Compassionate Human Factors in Healthcare, created by the Simulation and Interactive Learning Centre (SaIL) at Guy’s and St Thomas’ NHS Foundation Trust (GSTT) in collaboration with Clod Ensemble’s […]
The NHS strives to learn from its mistakes but is often criticised for failing to investigate incidents properly, and for failing to share lessons learned more widely.
This report is a redacted report from a Never […]