Focusing the Safety Spotlight: How Safety Intelligence Can Inform Systemic Patient Safety Initiatives

Author(s):  
Anthony Soung Yee ◽  
Trevor Hall ◽  
Tracey Herlihey ◽  
Jennifer Jeon ◽  
Patricia Trbovich ◽  
...  

This panel discussion at the 2021 Human Factors and Ergonomics Society (HFES) Healthcare Symposium (HCS) touched upon several topics related to actioning safety intelligence to improve patient safety. The panel had representation from both Canada and England across a broad range of human factors expertise in healthcare: from the perspective of academic research, operational hospital work, patient safety incident investigation and national healthcare policy, and a nationwide healthcare liability insurer. The panelists began with defining safety intelligence and distinguishing between safety intelligence and safety wisdom. The panel provided an engaging and insightful discussion on several topics including data collection, analysis and actioning upon the insights gained. In addition, the panel discussed strategies for demonstrating value in improving patient safety, and emphasised the importance of aligning one’s work with existing initiatives in the organisation, as well as the importance of collaborating with various stakeholders across the system to affect meaningful change.

Author(s):  
Barbara Streimelweger ◽  
Katarzyna Wac ◽  
Wolfgang Seiringer

‘Patient Safety' tries to increase safety and transparency within healthcare systems for both patients and professionals. Within the healthcare sector, workflows become more and more complex, while time and money become scarce. As a consequence, the risk awareness, fault management and quality aspects become more important. One of the most well established risk assessment method is Failure Mode and Effect Analysis (FMEA) – a reliability analysis and risk assessment tool widely used in various industries. The traditional FMEA is using a Risk Priority Number (RPN) ranking system to evaluate and identify the risk level of failures, and to prioritize actions. However, there are several shortcomings in obtaining a quality estimate of the failure ratings with FMEA, especially when human factors play an important role. Thus, a new risk assessment method called HFdFMEA (Human Factor dependent FMEA) based on the dependency of used parameters and the observation of human factors, is proposed to address the drawbacks. The opportunity to improve patient safety is discussed as result of HFdFMEA.


Author(s):  
Carrie Reale ◽  
Jason J. Saleem ◽  
Emily S. Patterson ◽  
Aaron Zachary Hettinger ◽  
Shilo Anders ◽  
...  

Medication management is a complex and mentally demanding endeavor performed by multiple individuals in diverse settings and at variable points in time. Achieving the goal of safe care delivery with optimized patient outcomes requires ongoing communication, coordination, and interaction between an array of technologies and roles across the health care continuum. Human factors principles and methods have the potential to substantially improve patient safety throughout this high-risk cycle. The purpose of this interactive discussion panel is to explore the medication management process from a sociotechnical perspective to identify specific challenges and vulnerabilities, and recommend strategies that leverage human factors processes and design principles to efficiently and effectively address safety critical issues.


Author(s):  
Peter A. Brennan ◽  
Rachel S. Oeppen

AbstractHuman error and organisational mistakes are a significant cause of morbidity for patients. It is important to recognise and address human factors (HF) in the context of our own performance optimisation, enhancing team working to improve patient safety, and better working lives for clinicians across surgery and medicine.


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