Safety science & human factors Martin Bromiley. Accidents were an unfortunate but accepted risk or complication of flying.

Slides:

Advertisements

Similar presentations

National Reporting & Learning System (NRLS) Reporting systems are vital in providing a core of sound, representative information on which to base analysis.

Advertisements

Every Cloud has a Silver Lining Ms Maire Bermingham Assistant Director of Corporate Support Services Dr Naomi Baldwin Senior Infection Prevention and Control.

Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.

Patient and public involvement in clinical audit

Building the highest quality services in the country Nigel Barnes March 2008.

Evidence Based Patient Safety Suzette Woodward Head of Patient Safety Improvement National Patient Safety Agency.

Healthcare Safety: How will your next patient be injured?

London Diabetes Strategic Clinical Leadership Group Dr Stephen Thomas Clinical Director for Diabetes, Strategic Clinical Network, London.

SAMPLE TITLE WHY MEASURING QUALITY IS IMPORTANT Hilary Cass President Elect, RCPCH PATRON HRH The Princess Royal.

Making Tomorrow’s Doctors Safer Patient Safety – the human factor Martin Bromiley.

MIND RESTRAINT REPORT INITIAL RESPONSE

Managing quality in trusts in England: time for a Chief Quality Officer? Nick Black Professor of Health Services Research London School of Hygiene & Tropical.

Responding to the Francis Report

South West Experience. How we went about Different Perspectives Findings Questions But first …………………..

Almagro 26 October 2006 Dr L J Patterson OBE MB FRCP Dr L J Patterson Consultant Physician OBE MB FRCP Quality of Care in UK National Health Service.

Learning from the Mid Staffordshire Experience Stephen Moss – Forman Chairman.

Protecting patients- now and in the future Linda Matthew Senior Pharmacist National Patient Safety Agency.

Patient Safety Culture

The Measurement and Monitoring of Safety Charles Vincent Health Foundation Professor of Psychology University of Oxford.

Patient Safety; Our Improvement Story Sue Smith Executive Director of Nursing & Patient Safety Director of Infection Prevention & Control.

The NHS Safety Thermometer 10 Steps to Success Series! Step 7 Training Staff.

Assessment of Team Skills in the Operating Room: Development and Evaluation of a ‘Train- the-Trainers’ Program Dr Louise Hull Research Associate, Department.

Strategic Education PartnershipMarch 2009 Working with our NHS Partners Tony Horne Dr Jeannette Bartholomew.

Improving the Health and Wellbeing of People with Learning Disabilities: An Evidence-Based Commissioning Guide for Clinical Commissioning Groups Dr Matt.

UK Council for Health Informatics Professions Why is professionalism important for health informatics staff and how do we assure it? Helen Sampson –Clinical.

Driving Better Safer Care 25 April Background Established May 2007 Independent – reporting directly to Minister for Health and Children Functions.

Sarah Bellars Director of Nursing and Clinical Quality

Scottish Patient Safety Programme – Paediatric Update Jane Murkin, National Co-ordinator, Scottish Patient Safety Programme Julie Adams, National Facilitator,

Inquiry process 4 panellists and 3 professional advisers Evidence briefing Written submissions from organisations Oral evidence sessions Professional.

Commission on Education & Training for Patient Safety.

Clinical Risk Unit University College London International Perspectives Feedback from the review board Charles Vincent Clinical Risk Unit University College.

LANCET COMMISSION PRESENTATION HEALTH CARE DELIVERY SYSTEM IN SIERRA LEONE BY DR EVA HANCILES.

A Regional Approach to Improvement Julie Branter Associate Director for Clinical Governance and Patient Safety 21 September 2010 South West Strategic Health.

Baseline assessment: Key findings Dr Jane Carthey Human Factors and Patient Safety Consultant Susan Burnett, Patient Safety Researcher & Consultant.

The Royal College of Surgeons of England Regional Representatives Meeting Simulator Training – in practice Implementation of a Surgical Skills Strategy.

Post Liverpool Care Pathway Arundel: 14 th May 2014 Dr Bee Wee National Clinical Director for End of Life Care.

Whistleblowing Summit Professor Jane Reid. Kohn 1999Donaldson 2000.

CHFG OPEN SEMINAR ROLE OF: CLINICAL DIRECTOR: CLINICAL HUMAN FACTORS, SIMULATION TRAINING AND ETHICS HYWEL DDA HEALTH BOARD Dr Matthew Sargeant.

The Comprehensive Unit-based Safety Program (CUSP)

Introducing Assistive Technology in Inpatient Services to Modernise NHS Mental Health Service Delivery Debbie Moores Allied Health Professions Lead South.

Services For Children & Young People Who Display Challenging Behaviour Well Matched and Skilled Staff A Pamphlet for commissioners Dr Sarah H Bernard Consultant.

Human Factors In a maternity service Making it happen Dr. Harriet Nicholls Consultant Anaesthetist Luton and Dunstable Hospital NHS Foundation Trust.

CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Revisiting Science of Safety & Identifying Defects ARMSTRONG INSTITUTE FOR PATIENT.

The role and design of NHS England. About us NHS England: was established as a special health authority on 31 October 2011 and as an executive non-departmental.

NHSScotland Event 2015 LEADING INTEGRATION FOR QUALITY B:6 Safe and Sound for Integration – Successes and Next Steps.

NHS England (North) – Parity of Esteem Meeting 1 st April Leeds 23 rd January 2014.

High quality care for all, now and for future generations Caroline Lecko Patient Safety Lead.

Patient Safety Collaborative Pressure Ulcer Harm Reduction Dr Paul Durrands Chief Operating Officer, Oxford AHSN.

Stakeholders in Patient Safety Who are they? Where are we now? How do we move forward? Mark Emerton Consultant Orthopaedic Surgeon Safer Care Programme.

Content from National Patient Safety Agency material 2 Day Lead Investigator.

Our application to become an NHS Foundation Trust.

Risk Management in the National Health Service in England Stuart Emslie Head of Controls Assurance Department of Health, England ISO General Assembly 2001,

The development of the Healthcare Safety Investigation Branch (HSIB) Dr Mike Durkin NHS National Director of Patient Safety 4 May 2016.

Patient Safety. Learning Objectives By the end of this session you should be able to; Give examples of areas of concern for patient safety and the situation.

Reducing the burden - improving services The Health and Social Care Information Centre Martin Machray Release: 1 April 2005.

IGA Conference Tuesday 22 November 2016

Title of the Change Project

Presented by :Claire Beynon

What is Leadership all about?

Mark Thorpe, RMN – Program Lead for the Centre of Perfect Care

Learning from the Mid Staffordshire Experience

INNOVATIVE, INTERPROFESSIONAL SIMULATION

Closing remarks Professor Priscilla Harries Head Of Department- Clinical Sciences Brunel University London NWLondon Healthcare Symposium 21st September.

Preventing VTE in hospitalised patients

Programme Board meeting

Why standards matter.

The Fit for Work UK Coalition:

RMU RESIDENCY PROGRAMS

Head of Corporate Governance/ Board Secretary

Our Team – Emergency Care Intensive Support Team

Presentation transcript:

Safety science & human factors Martin Bromiley

Accidents were an unfortunate but accepted risk or complication of flying.

In aviation all accidents are considered avoidable……..

Patient Safety 3,283 patients dead through preventable error, another 7,000 suffer severe harm (Data for England, published in Parliamentary Inquiry to Patient Safety 2009)

Patient Safety 3,283 patients dead through preventable error, another 7,000 suffer severe harm Equivalent to 9 medium size aircraft (Boeing 737/Airbus A320) being written off with total loss of life every year…… …..in the UK!

Investigation (technical & non-technical/HF)

Simulation and frontline understanding of “HF” and non-technical skills (knowledge, examination, assessment)

Investigation (technical & non-technical/HF) Simulation and frontline understanding of “HF” and non-technical skills (knowledge, examination, assessment) Balancing safety and productivity

Investigation (technical & non-technical/HF) Simulation and frontline understanding of “HF” and non-technical skills (knowledge, examination, assessment) Balancing safety and productivity Ergonomic design

Frontline “Systems” and approaches Mental rehearsal/simulation Briefings Checklists Time out and “speaking up” SOP’s Equipment design/training

Leadership Tools Walkrounds and banishing “workarounds” Culture survey Managing incidents/reflection on incidents Review reporting rate Training Encouraging speaking up

Clinical Human Factors Group We are independent, impartial, and work in a voluntary capacity… Our vision is to engender human factors thinking in the hearts and minds of all healthcare staff and stakeholders. From board to ward and beyond…

Some of the CHFG “Team”over the last 3 years…. Prof Jim Reason – Univ of Manchester Dr Jane Carthey – HF Specialist The late Prof Helen Muir – Cranfield Prof Rhona Flin – Aberdeen University Tony Giddings - Former member of the Council of the Royal College of Surgeons Eng Jane Reid – President, International Federation of Perioperative Nurses Chris Sadler – Consultant Anaethetist & Director of Barts and The London Medical Simulation Centre Clare Bowen Matthew Sargeant – Hywel Dda Health Board, Consultant Psychiatrist Cate Quinn – Care Quality Commission Prof Charles Vincent – Imperial Karen Woo - BUPA Nikki Maran – Scottish Clinical Simulation Centre Peter McCulloch – QRSTU Oxford Linda Watterson – Royal College of Nursing Allan Goldman – Consultant Intensivist Mark Emerton – Orthopedic Surgeon Stephen Ramsden – Chief Executive L&D NHS Trust Dr Melinda Lyons & Bev Norris – HF Specialists representing the NPSA Hugh Rogers & Nikki Davey – representing the NHS Institute Simona Arena – Health Foundation Prof Nick Barber – Prof of the Practice of Pharmacy, Univ of London Emma Stanton – BAMMbino Sir Ian Kennedy – Chair of HCC

In aviation 75% of accidents are caused by human factors… …what’s the figure in healthcare?

Consultant Anaesthetist ENT Surgeon Senior ODP ODP Recovery Nurse

Thank you…… Copies of a DVD covering human factors in healthcare can be obtained free of charge from “HF How to guide” can be downloaded from ?path=/Campaign-support/human-factors/ ?path=/Campaign-support/human-factors/