Patient Safety / Simulation and Ergonomics

Distractions  Following a slight blogging holiday (bloggiday?) I thought it would be interesting to think about distractions - recently I helped deliver a human factors session at Walsall Manor Hospital, supporting a fantastic local Human Factors initiative that had seen a real culture change within the organisation.   The session I led was around distraction and cognition and allowed me over the day to start to draw together the discussions into some type of working model on how to reduce distractions.  The problem Fundamentally, I really do think that distractions are so commonplace in healthcare they are seen as the norm - to such an extent we are blind to them  how many times will the consultant in ED running the trauma call be asked to look at a 12 lead ECG for another patient in majors listen to the melee of alarms screaming for attention in a critical care area the staff member waiting slightly impatiently to discuss another patient while ...

So up until now my blogs have focussed on the individual elements of patient safety, simulation and human factors but not really brought them together into a unified piece of work - so here we are - what does Patient, Safety and Human Factors have in common and how can they collaborate to improve patient safety? This actually is very timely too, as it links to the recent Opening Doors (link)  publication from the CQC recognising that we are not reducing Never Events and signalling the need for an improved safety culture and the fact that NHSI are currently developing a Patient Safety Strategy link that aims to half avoidable harm in the NHS. What is clear is that there is some really good examples of good practice and activity going on within NHS organisations but there seems to be a lack of a way to scale up and share these. I do also think this is not just an issue for or with NHS organisations as indeed the same culture exists, and to an extent is reinforc...

Over the last fifteen years there has been a shift from only delivering simulation sessions in a designated simulation area to more simulation being delivered in clinical areas in so called in-situ simulations. Clearly in-situ simulation offers the ability to increase simulation capacity and become more inclusive, but sometimes it is claimed to be the optimal place to deliver simulation - it may offer lots of benefits but it isn’t without some degree of risk. Benefits - the ability to simulate in the participants clinical area, with their clinical equipment and their team has clear benefits and we know that all to often staff sent for simulation in a dedicated area, will be cherry picked and will not be representative of the skill mix in the real environment. Also, as it is the real working area, it also enables detection of those ergonomic issues (or latent issues) i.e. when people coming from different areas can’t find the location, equipment isn’t available etc. Worklo...

In this weeks blog I want to really discuss Ergonomics and start to think about how this is understood, or not, in healthcare.  My interest in this area started years ago - delivering simulation I started to get invited, or invite myself, to a variety of trust (organisational) meetings focussing on a number of quality improvement areas. Topics that have probably been procrastinated on around the world in healthcare organisations such as   patients slips and falls how to spot the deteriorating patient  rates of infection in central lines and urethral catheters ….etc  What I realised over a period of time was that I was having very similar conversations with each disparate group i.e. whilst we focussed on very specific clinical elements there was some unseen presence in the shadows that was not recognised - maybe this entity offered a solution across the range of clinical issues and maybe even a solution to issues we were not looking at!   Initially ...

When you discuss starting a simulation programme with individuals in a department (or ward etc) there is often a point where the opportunities of simulation almost become overwhelming. There are so many potential simulation areas that could be addressed that often people are unsure where to start.   Over a period of time I have developed a mental model on how to engage and develop a departmental simulation programme in a step wise approach within a department or area. It also works at an organisational level though this blog concentrates on the department level.  The first thing is to realise that all the different groups need to be engaged with the simulation; there is no point in having one professional group, leading and mandating others attend - as there is a risk that it will be seen as the group needs these people as “props” for their own training - the other people will feel that they will not get anything from the sessions. It is important that all the group...

This week I wanted to carry on with the simulation theme and consider the diseases and conditions we often simulate.  If we start to describe our simulation scenario our participants will often second guess our scenarios - often correctly, just think of the common introductions  The patient has just been given antibiotics [ anaphylaxis ]  The patient has just returned from theatres [ massive haemorrhage ]…… and so the list continues.  Of course the interesting thing to realise is that in our hospitals countless patients have antibiotics each day without anaphylaxis and the majority of patients return from theatres and make uneventful recoveries. In fact the recent 6th National Audit Project of the Royal College of Anaesthetists looking at perioperative anaphylaxis  ( NAP 6 )  found out of three million patients there was a 1:10,000 occurrence of anaphylaxis compared to a probable 1:1 occurrence in simulation population following ...