20 th and 22 nd September 2011.  Facilitators ◦ Adam Figgins ◦ Adrian Hayes ◦ Rosalind Pool ◦ Siobhan Reilly ◦ Poppy Roberts ◦ Chris Roughley ◦ Tommy.

Slides:



Advertisements
Similar presentations
DEATH BY MEDICAL ERROR THE HIDDEN EPIDEMIC. By William Charney Editor of Epidemic of Medical Errors and Hospital-Acquired Infections.
Advertisements

What Can the Operating Room Learn from the Cockpit?
Patient Safety An Overview Patient Safety is freedom from injury or illness resulting from the processes of healthcare NQF 2001.
What is Child Life? Your Name, Institution, Etc..
Patient Safety What is it? Why is it important? What are we doing? What is my part to play?
Ask Me Anything American Nurses Training Association.
F1 projects surgical handover
ELMBROOK MEMORIAL HOSPITAL PILOT START DATE 7/30/2012 – DAY SHIFT END DATE 8/29/2012- NIGHT SHIFT Fall Safety Huddles.
30 Safe Practices for Better Health Care AHRQ. Background The goal in the United States is to deliver safe, high-quality health care to patients in all.
Quality Patient Care Is Frequently Measured The Communication Systems Prevalent in Nursing Units. Through Analysis of.
How Safe is Your Hospital?
Turning Questions into Trials: Innovation in Surgical Oncology Jennifer E. Rosen MD FACS Assistant Professor of Surgery and Molecular Medicine Boston University.
CLINICAL GOVERNANCE A Framework for High Quality Care Marian Balm Sir Charles Gairdner Hospital.
Electronic handover (eHandover): towards safer medical care Quality Improvement Team: Dr. Adam Hexter, FY1 Doctor at Manchester Royal Infirmary, CMFT Mr.
Resilience and Well-being in a Scottish Police Force
Developing a Trust wide framework to support Nurse Facilitated Discharge to reduce length of stay Kate Pound and Sue Haines Service Redesign Manager Assistant.
Brock Delfante Pharmacist Sir Charles Gairdner Hospital
Handovers: a measurement and interventional framework Eleanor Robertson MB ChB, BMSc (hons), MRCS Clinical Research Fellow QRSTU, University of Oxford.
Which skills do junior doctors require to prescribe safely? Dr Effie Dearden StR General Medicine & Geriatric Medicine Fellow in Medical Education.
© 2008 The Board of Trustees of the University of Illinois Collaborative Learning From Patient Safety: Presentation From PSOs and International Patient.
Presented to [Date] By [Insert Name] The Application of FMEA to a Medication Reconciliation Process.
Safer Medicines Outcomes on Transfer Home
Framing and Measuring Patient Safety Dr Jeanette Jackson This SPSRN work is funded by.
The Health Roundtable Do Electronic Medication Systems Impact Patient Safety: What do the Frontline Clinicians Think? Debono, D. 1, Greenfield, D. 1, Black,
Hard Work and Vigilance: Necessary but Insufficient The Role of Human Factors in General Practice Dr Richard Jenkins Tuesday 2 nd November 2010.
Topic 5 Understanding and learning from error. LEARNING OBJECTIVE Understand the nature of error and how health care can learn from error to improve patient.
ACOVE 4: Continuity and Coordination of Care in Vulnerable Elders Continuity is ‘‘care over time by a single individual or team of healthcare professionals’’
SAFE SURGIES CHECKLIST A PATH TO PATIENT SAFETY Rola Hammoud, MD,DA,MHM.
IV Cannulation of Patients with Fractured Neck of Femur
Leroy Edozien Consultant in Obstetrics & Gynaecology St Mary’s Hospital, Manchester, UK.
RESEARCH PROGRAM UPDATE Sarah Castro, MPH Senior Research Support Liaison.
Medication errors and patient safety Vic Vernenkar, D.O. Department of Surgery St. Barnabas Hospital.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 10Safety Concerns in Healthcare.
Students F1  Review admissions  Clerk patients  Make clinical management plans  Review acutely ill patients in the ward  Attend alert calls.
Patient Safety & Clinical Quality: Information Technology at THR Internal Medicine Update Presbyterian Hospital of Dallas October 29, 2003.
Introduction The American Nurses Association estimates that eighty percent of serious medical errors involve miscommunication between caregivers when patients.
Applying for Medicine at Bristol Dr Alice Roberts.
L o g o Patient safety during medication administration: The influence of organizational and individual variables on unsafe work practices and medication.
Patient Safety Vince Watts, MD, MPH. Topics Patient Safety –Overview –Tools –Emerging issues Change –Theories/models of change –How to lead change.
Janet Lin, MD, MPH, Sweta Basnet, MS, Sara Baghikar, MD, Cammeo Mauntel-Medici, MPH, Sara Heinert, MPH University of Illinois at Chicago, College of Medicine,
PATIENT SAFETY LESSONS FROM OTHER COUNTRIES Alberto R. Ferreres.
Handover and Written Communication Dr Karen Arnold October 2014.
Human Factors in Healthcare Education Chris Hancock – Programme Manager, Rapid Response to Acute Illness (RRAILS), 1000 Lives Plus.
Introduction Results Curricular Design Patient Safety Leadership WalkRounds™ were first introduced at Partners Healthcare in Engage frontline staff.
Dr. Rashida Abdelfattah FACULTY OF NURSING SCIENCES University of Khartoum.
Strategies and Tools to Enhance Performance and Patient Safety Adoption in Action AHRQ funded project UNCHCS/RTI partnership READY Training OR 6.
PST Human Factors Jan Shaw Manchester Royal Infirmary CMFT.
Strategies and Tools to Enhance Performance and Patient Safety Adoption in Action AHRQ funded project UNCHCS/RTI partnership.
POOR SURGICAL TEAMWORK & SAFTEY ATTITUDES: THE UNSPOKEN NORM Kirengo T, Nyotu R, Ndanya S, Gitonga S.
Patient Safety Take a little time to read through these slides, where a question is asked stop and consider it for a few moments before going on to the.
Improving the safety and quality of the GP practice repeat prescribing process Helen Marlow and the Medicines Management Team, Surrey Downs Clinical Commissioning.
National Sepsis Summit Dublin Castle 2016
Medical Leadership Influencing Culture and Patient Safety
Operating Room Nurse to Post Anesthesia Care Unit Nurse Handoff: Implementation of a Written SBAR Intervention Erin Long BSN, RN, DNP Student The unique.
THE USE OF A WRITTEN ASTHMA ACTION PLAN IN PATIENTS DISCHARGED FROM THE EMERGENCY DEPARTMENT OF THE MATER MISERICORDIAE UNIVERSITY HOSPITAL Dr. Nafisah.
APPLYING HUMAN FACTORS METHODS AND APPROACHES
TOOLS FOR PERFORMANCE IMPROVEMENT – Can the checklist BE the answer?
Development Policies and Procedures Manual
Communication & Safety
2.13 Copyright UKCS #
30 Safe Practices for Better Health Care
ايمني بيمار PATIENT SAFETY حق بيمار و مسئوليت ما
Medication Related Incidents on PICU
وزارت بهداشت درمان و آموزش پزشکی معاونت درمان
Dr Anita McCarron Consultant in Anaesthesia UCL Hospitals
Medical Errors Zheng Yan Advised by: Dr. Dan France, Ph.D, MPH.
Programme Board meeting
Fighting Sepsis – Saving Lives
Physician Interruptions in the Emergency Department
Peer Led Simulation Tracey Valler Richard Standage
Presentation transcript:

20 th and 22 nd September 2011

 Facilitators ◦ Adam Figgins ◦ Adrian Hayes ◦ Rosalind Pool ◦ Siobhan Reilly ◦ Poppy Roberts ◦ Chris Roughley ◦ Tommy Salter ◦ Jessica Scott ◦ Sarah Watson ◦ Rebecca Woodside Dr Vinod Patel, WMS Institute for Applied Teaching and Learning

 7:00 – 7:30 Introduction  7:30 – 7:45Station 1  7:45 – 8:00Station 2  8:00 – 8:30Refreshments  8:30 – 8:45Station 3  8:45 – 9:00Station 4

 Consent Form  Questionnaires ◦ Before and After  Interviews  Follow-up  Please complete Before questionnaires now

 The freedom from accidental injury due to medical care or from medical error (Institute of Medicine 2000)  ‘doing the right thing to the right person at the right time, getting it right first time’ (Ambrose, 2009)

“If you fly on a plane, you have a one in 10m chance of being killed. If you go into hospital, you have a one in 300 chance – and not from the illness you went in with.” Richard Branson

Amalberti et al, 2005

 Why? ◦ Heavy workload ◦ Fatigue ◦ Stress ◦ Shift work ◦ Reliance on memory ◦ Reliance on vigilance ◦ Noise ◦ Distractions ◦ Unnatural workflow Watson, 2010

Reason, 2000

 Just a Routine Operation Just a Routine Operation

 Protocols and checklists  Constraints  Forcing functions  Encouraging function  Discouraging functions  Leadership and Culture

 Recommendations ◦ BMA ◦ GMC ◦ WHO  Little formal teaching Walton et al, 2010  RISC initiative

 How to prepare for surgery  How to hand over a patient  How to recognise an ill patient, and what to do about it  How to spot an unsafe clinical event, and what to do about it

 3 rd and 4 th year students  3 grants  1 publication (in press)  17 projects ◦ Handover ◦ ED Admissions ◦ Sepsis ◦ Medication Error Audits ◦ Surgical Safety Checklist ◦ iPhone App ◦ Uniforms for Medical Students Get Involved!

 Patient safety is important (and interesting)  Medical students can contribute