Two Views on Human Error
Johan Bergstrom – Lund University presents two schools of thought on Human Error
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Technical Failure or Human Error
Johan Bergstrom – Lund University on Human Factors and Systems Safety
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Guidance for Human Factors Evaluations in the Procurement of Medical Devices, Equipment and Technology
The Guidance for Human Factors Evaluations in the Procurement of Medical Devices, Equipment and Technology document provides comprehensive recommendations on how one may integrate human factors evaluations into procurement processes.
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Joint Committee published report on Health Service Safety Investigations Bill
The House of Lords and House of Commons created a Joint Select Committee to review the draft Health Service Safety Investigations Bill…
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World Health Organisation – 10 global facts on Patient Safety
Patient safety is a serious global public health concern. There is a 1 in a million chance of a person being harmed while travelling by plane. In comparison, there is a 1 in 300 chance of a patient being harmed during health care. Industries with a perceived higher risk such as the aviation and nuclear industries have a much better safety record than health care.
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HSIB Investigation report – transition from child mental health services to adult
This investigation followed the Healthcare Safety Investigation Branch being notified of an 18-year-old who died by suicide shortly after transitioning from child and adolescent to adult mental health services. The investigation identified possible issues regarding the transition process.
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Updated Just Culture Guide – NHS Improvement
NHS Improvement have updated their Just Culture Guide.
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HSIB first national investigation report – wrong prosthesis
The Healthcare Safety Investigation Branch (HSIB) has published its first investigation report relating to a surgical never event.
The patient is a 63-year-old man who underwent hip replacement surgery. During this surgery, incompatible components were used. The error was identified when data from the procedure was recorded in the National Joint Registry.
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Draft Health Service Safety Investigations Bill
The draft bill proposes setting up the Health Service Safety Investigations Body (HSSIB). The HSSIB will conduct investigations which focus on learning from patient safety incidents in the NHS, to reduce health care harm and improve patient care.
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