By Ms Melanie Newton, Senior Lecturer in Adult Nursing of School of Health & Social Care Teesside University for the 8th Smart Health Community of Practice (CoP) Forum: Human Factors in the Digitalisation of Healthcare.
4. Scan4Safety initiative (Carter 2016)
• Barcodes are being used to trace NHS patients and their treatments,
manage medical supplies and monitor the effectiveness of equipment.
5. Did you hear about Alice?
• Scenario- Residential Care Home for Older Adults
• Incident – Alice took a fall, she has hearing impairment and early dementia
• Care staff arranged for Alice to go to hospital
• Mary, the new Care Assistant would accompany Alice to hospital….
6. When something goes wrong…
• Why do people break the rules?
• What about safety reporting and honest disclosure?
• How do we maximize learning to prevent recurrences?
7. Final thoughts about how to enhance a safety culture
1. Focus more on behaviour, less on procedures.
2. Support patients & families to make the experience better for everyone.
3. Visibly support staff when things become difficult, so they feel safe to be open and honest.
4. Invest in building good relationships with commissioners & regulators, they have a substantial
impact on culture.
8. Thank you
For more information about safety culture and human factors,
please contact me:
m.newton@tees.ac.uk
This underpins the principles of human factors
People don’t work as individual beings – they adopt the cultural norms of where they work.
My interest is around fair and just cultures and the work of Sydney Dekker.
This infographic shows the dimensions of Human Factors
Product- to provide patient healthcare service from pre-cradle to grave.
Task- assess, plan, diagnosis, provide treatment, symptom control and compassionate care. Differs depending upon role within the organisation.
Environment- heat, noise, lighting - complex from patients own home settings to acute hospital care to residential care facilities and in-between
User- patients/families who may also be staff members
Different to other industries in many ways… not a single service provision like transport or energy industries
An evidence-based scientific discipline that uses a design-driven systems approach to achieve two related outcomes of performance and well-being. It applies the elements psychology, anatomy and physiology, social sciences, engineering, design and organizational management, and combines them to better understand the nature of human-technology-systems interactions. These systems, and context, include people, products, technology, organizations and environments. (CIEHF 2018)
NTS-
The barcode technology – we have all seen it in the supermarkets
introduced to the NHS in England to improve patient safety.
Barcodes are being placed on breast implants, replacement hips, medication and surgical tools.
The £12 million Department of Health ‘Scan4Safety’ project is already helping staff to quickly and easily track each patient through their hospital journey. From the unique barcodes on wristbands patients receive when they enter hospital, to the barcodes used to record their medication and the equipment used in their treatment, each code can be scanned to show which member of staff administered each treatment, at what time and where.
By using barcodes, anything that might develop a fault years later, for example a screw used in a knee operation or breast implant, can be traced. The details, such as when it was used and the surgeon who carried out the procedure, can be found quickly and easily.
Early results from 6 pilot projects show the potential to save up to £1 billion for the NHS over 7 years.
Secretary of State for Health Jeremy Hunt said:
Scan4Safety is a world first in healthcare – and a vital part of this government’s drive to make the NHS the safest and most transparent healthcare system in the world.
Scan4Safety removes human inventory errors, and registers ‘use-by’ dates on medicines and equipment so that stock can be managed easily and patients given the most appropriate medicines.
Scan4Safety can also be used to see how effective different equipment is, for example, if one type of hip replacement wears out more easily than another, improving patient outcomes and helping to make the health system more effective.
Mary had been in the Care Home for two shifts and was just getting to know the residents
Alice and Doris look alike
Mary goes to the office (no one else there) and selects the medical notes to take to hospital with Alice – except she selects Doris’ notes my mistake
At A&E Mary hands over the medical notes to the Nurse who arranges for the barcode information to be applied to a wristband
Two days later the Care Home staff contact the hospital to see how Alice is getting on
‘we don’t have an Alice on the ward’….
Would a different system be better?
What would typically happen where you work?
What does the policy say and what actually happens? ‘Workarounds’
How do we investigate errors –
instead of investigate, should we have conversations to understand what happened?
instead of obtaining a statement, should we ask about the views and opinions of those involved?
What is the culture?
Is there a ‘fair and just’ culture to enhance learning from mistakes?
Mersey care Dekker
Taken from a focus group who advise about implementation of a fair and just culture…
Focus more on behaviour & less on procedures to change culture. – be attentive to language used when investigating an incident. Don’t set up an investigation but share a conversation. Don’t take a statement but get the person’s views about what happened. Importance of soft skills. ‘scrutinise without intimidating’.
Support patients & families affected by patient safety incidents to make the experience better for everyone. Patients and families require support and deserve to know what happened. Invite randomly selected families to attend Trust board meetings for good and bad views. Balance the needs of distressed patients and staff so that both are treated fairly.
Visibly & actively support staff when things become difficult, so they feel safe to be open and honest. Promote psychological safety and acknowledge that fear is complex, everyone is fallible. The need to suspend staff ‘pending investigation’ should be reviewed but staff need to be honest about being unable to perform safely even with all possible support. Consider managing ‘legal services’ within the safety and governance team as a supportive resource. Freedom to Speak Up Guardians can be useful.
Invest in building good relationships with commissioners & regulators as they have a substantial impact on culture. The tone that a regulator sets can have a disproportionate effect on staff when things go wrong.
