Should we be using measurements to standardise good practice? Nikki Davey, CHFG Trustee
Nikki Davey, Clinical Human Factors Group Trustee, illustrates how the challenges of making changes to improve patient safety are different across different Trusts, for example, using ‘my name is’ movement – the cultural challenges can be...
Contributory factors in surgical incidents as delineated by a confidential reporting system
Confidential reporting systems play a key role in capturing information about adverse surgical events. However, the value of these systems is limited if the reports that are generated are not subjected to systematic analysis. The aim of this study, by the Royal...
Systems thinking – a new direction in healthcare incident investigation
The Health Foundation’s Evidence into Practice Programme sponsored the production of a 3 minute animation led by Thomas Jun and Patrick Waterson at Human Factors and Complex Systems Research Group, Loughborough University. This highly engaging and insightful animation...
TED Time Escalation Decision Learning package
Hypoxic Ischaemic Encephalopathy (HIE) occurs when the foetal brain does not receive enough oxygen. This can lead to severe impairment or death of the baby and is of course devastating for both families and staff. Whilst there have been a number of similar cases at...