TO ERR IS HUMAN… to improve is learning
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magine this scenario. Mary is admitted to the ward and is scheduled for an operation. She has insulin dependent diabetes. Her nurse notices that insulin has not been prescribed by the admitting doctor. She contacts the doctor on call to prescribe the insulin. When the doctor arrives to the ward, the nurse is on her tea break. She left a message for the doctor to come to see her in the break room to discuss it further. The doctor insists that the nurse returns to the ward to discuss the matter. The nurse leaves her tea break and has a disagreement with the doctor about the situation. The doctor is annoyed that the nurse “doesn’t have the manners to come out to the office from her break to discuss the issue”. The nurse feels the doctor could just have come to the tea room. The Clinical Nurse Manager (CNM) is asked by the nurse to intervene in the disagreement. Both the doctor and the nurse agree that they were stressed and tired. The nurse has a heavy caseload of sick patients and this was her first time to have a break in hours. The doctor has three wards to cover and is working alone. The manager mediates in order to get the best possible outcome. The manager feels “calmness and understanding is required”. The insulin is prescribed and Mary is safely taken to theatre for her operation.
compassionate health service, one that learns when things go wrong, responds accordingly and reduces harm to those who entrust their lives and care to us. We provide this care through our seven teams: • Patient Safety Programme • QPS Improvement • QPS Intelligence • QPS Incident Management • QPS Education • QPS Connect • National Centre for Clinical Audit
The Directorate is led by HSE National Clinical Director, Dr Orla Healy (working within the Office of the Chief Clinical Officer). A native of Cork, and a graduate of UCC, Orla has worked and trained in Hospital and Public Health Medicine, has extensive experience in community and hospital group management, and health service improvement. Orla hopes “to engage and collaborate with the health system to co-design quality and safety improvements”. Co-design in healthcare involves a partnership between healthcare staff, patients (and their families and carers)
WHAT IS HUMAN FACTORS? The story above shows us how the individual behaviour, the job we do, and the organisation’s supports contribute to safe care. In healthcare the focus for Human Factors has been to improve patient/service user safety. However, Human Factors also have much more to offer to the areas of quality improvement and efficiency. Safety Improvement – A Human Factors approach can support our understanding of the contributors to incidents at all levels of the healthcare system, as well as how to proactively improve safety through mitigation. Quality Improvement – Human Factors approach can support improvements in quality of care, work practices and workforce satisfaction. Increased efficiency - A Human Factors approach can support an improved understanding of how work processes and systems can be designed in order to optimise performance and productivity and cost effectiveness The National Quality and Patient Safety Directorate launched an Introductory Guide to Human Factors. The Guide is written for all healthcare workers and aims to use Human Factors to improve patient and staff safety in healthcare. Our full Guide can be accessed on our website www.hse.ie/eng/about/ who/nqpsd/qps-incident-management/incidentmanagement/a-guide-to-human-factors-inhealthcare-2021.pdf along with a summarised graphic www.hse.ie/eng/about/who/nqpsd/qpsincident-management/incident-management/ human-factors-guide-infographic.pdf Follow us on @NationalQPS for your daily updates on quality improvement and patient safety.
and the “designers” of the new system. Orla reminds us that “the Patient Safety Strategy anchors all that we do in the NQPSD” and believes patient safety is everyone’s business. As such, we invite those in the health system to engage and work with us in our ambition to improve quality and patient safety. For example, this past November, the NQPSD worked with HSE quality and patient safety leads across the system to launch an introductory guide to Human Factors, with the purpose of using these principles to improve safety, quality and efficiency.
MORE INFORMATION: You can read more about our work and teams at www.hse.ie/eng/about/who/nqpsd/ We would love to hear from you and encourage you to reach out to us on nqps@hse.ie and follow us on Twitter @NationalQPS.
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