Coming back from the mediterranean we witness an interesting dilemma: the plane can't take all passengers. Volunteers are needed to stay behind.
The Health Foundation has just finished its 1st Innovation labs with a project on peer support.
Being worried might be an important mechanism of protection. Healthcare professionals, patients and their families can use it to contribute to patients' safey in hospital.
Stuart works through his routine using a system that keeps things safe. His lessons matter beyond his working environment.
When things go bad in hospital - how can patients get help? Experts agreed this week that patients should be able to call a Rapid Response / Critical Care Outreach / Medical Emergency Team directly.
Just in case you missed it between the headlines about beating Panama and ghosts of penalties past: The NHS is finally reached its 70th birthday. There is a lot of noise on achievements and some notes on the roots in a philosophy originating from miners working in Wales. The Tredegar Medical Aid Society became the... Continue Reading →
Safety in hospital costs a lot of money, much of it hidden. But the output is abysmal. Time to go to mid-Wales to learn?
On Wednesday evening I am coming back up the coast while the sun goes down over Anglesey. Three days of learning and reflection with the HealthFoundation’s Improvement Science Fellows in Cambridge. This is an annual get-together of specialists in Improvement Science now hosted by THIS institute. The careful analysis and development of new solutions for patient... Continue Reading →
And a great summary about systems approach to failure.
In the event of failure (ha ha ha, I couldn’t resist that), this is what I’m aiming to cover….
The Swiss Cheese Model of Accident Causation (to give it the full name), was developed by Professor James T. Reason at the University of Manchester about 25 years ago. The original 1990 paper,“The Contribution of Latent Human Failures to the Breakdown of Complex Systems”, published in the transactions of The Royal Society of London, clearly identifies these are complex human systems, which is important.
Well worth reading is the British Medical Journal (BMJ), March 2000 paper, ‘Human error: models and management’. This paper gives an excellent explanation of the model, along with…
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