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Human factors

Overview

Human factors

October 28, 2012

Human factors play a key role in safety culture and in accident causation. Effective safety management is a crucial determinant of the safety culture of the organization. 

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“Paging Dr. Strong” and Other Confusing Hospital Emergency Codes

February 8, 2016

Hearing “Paging Dr. Strong” on the intercom system does not necessarily mean the operator is summoning an actual Dr. Strong. Some facilities use that code to call in the security guards to deal with misbehaving patients or visitors. Code Silver in one hospital may refer to “missing person” and in another “somebody with a gun.” These codes might be standardized across a hospital or a hospital system, but there is little standardization across regions or states.

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Lessons Learned

Abbreviations in Patient Communications

February 6, 2015

Rules for abbreviation use generally focus on medication safety—identifying visual and textual ambiguities that may confuse other medical professionals. The ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations includes items like IU that could appear like IV or 10; and DPT, which could stand for Demerol-Phenergan-Thorazine or diphtheria-pertussis-tetanus.

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Good or Lucky?

October 21, 2013

One barrier to change is resistance by those who have not experienced a bad event. Most of us were trained to learn from our personal experience; quite useful in many situations, especially when scientific evidence is weak or absent. Given the vast variety of situations patients present with and the limits of scientific evidence, there are many situations in which human intuition and experience are valuable. You can often hear experienced professionals say that they made a “gut” decision; one made from instinct and intuition developed through their own experiences.

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Is training ever useful?

October 10, 2013

A frequent response to an adverse event is to retrain the staff. However, training is often criticized as a very weak and inappropriate response to problems, unlikely to result in significant sustained improvement. That criticism is correct, to a point.

A recent paper discusses the difference between appropriate and inappropriate training from the human factors standpoint . Training as the sole or primary intervention may be of marginal value as system design issues are often part of the problem.

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Understanding adverse events
A human factors framework

November 7, 2012 Henriksen K, Dayton E, Keyes MA, et alPatient Safety and Quality: An Evidence-Based Handbook for Nurses (Chapter 5). AHRQ Publication No. 08-0043, April 2008.

This Agency for Healthcare Research and Quality (AHRQ) handbook examines the broad range of issues involved in providing high quality and safe care in all health care settings. This section of the guidebook provides a framework for collaboration between health care and human factors, and addresses the interdependent system factors that underlie patient safety.

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Implementing human factors in health care

November 7, 2012 National Health Service Patient Safety First Campaign

This guide provides an introduction to the concept of human factors in
health care and provides suggestions of how its elements can be applied by individuals and teams working to improve patient safety. It aims to build awareness of the importance of human factors in making changes to improve patient safety.

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Patient safety
Human factors tools

November 7, 2012 World Health Organization

World Health Organization (WHO) Patient Safety has identified human factors measurement tools falling into four categories: organizational/managerial, team, individual, and work environment. The tools within each category fall into numerous categories, including communication, decision-making, and situation awareness. 

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Human factors in patient safety
Review of topics and tools

November 5, 2012 Report for Methods and Measures Working Group of WHO Patient Safety, April 2009

This document provides an overview of human factors relevant to patient safety, with a discussion of tools that can be used in the healthcare setting.

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The end of the beginning
Patient safety five years after ‘To Err Is Human’

August 10, 2012 Robert Wachter

This paper examines the genesis and impact of the Institute of Medicine (IOM) report on medical errors, To Err Is Human, and takes stock of where we are five years after its release.

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Human errors
Models and management

August 9, 2012 James ReasonDepartment of Psychology, University of Manchester

The basic premise in the system approach is that humans are fallible and errors are to be expected, even in the best organizations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in “upstream” systemic factors … Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work … When an adverse event occurs, the important issue is not who blundered, but how and why the defenses failed.

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Becoming a safer organization

  • Human factors
  • Leadership
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  • Working as a Health Care Team

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August 22, 2012
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CHPSO is a division of the Hospital Quality Institute

July 11, 2014
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August 22, 2012
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August 22, 2012
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