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Patient
Safety & Quality

Aiding Threat & Error
Management Programmes

Prof. Stephen Brecker, Head of Cardiology, was contrasting Aviation Safety  with Patient Safety in Healthcare, and approached Critical Factors to understand where the differences lay. Following initial discussions it was agreed that Critical Factors would observe an “ordinary” day in the Catheter Lab at St George’s.

Initial findings were reported, and it was recognised that a bespoke Human Factor training solution would deliver the following benefits as part of a Threat and Error management programme:
 

better
understanding of
the team situation
improved
awareness of the
patient
effective
checklist
application
enhanced
communication
simple, effective procedures for
when situations
arise
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Further fly-on-the-wall observations were carried out by the Critical Factors team, drawing on their experience as Human Factor trainers and assessors in analysing team interactions.
All Catheter Lab staff (across all disciplines) were surveyed to obtain a deeper understanding of any both personal perceptions of staff members and any issues that not presented whilst observations were conducted. Data was sought from management reports too.
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A bespoke training package was then created, focusing on how in practice to change the way front-line professional teams interact most effectively to best protect the patient, and support each other. This included development of new standard procedures and protocols, a significantly amended WHO checklist and other key support materials.

Human Factor “Champions” were appointed within the Catheter Lab to receive phased intense training, to act as role models within the unit and deliver further training to all Catheter Lab staff.

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