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Atrainability Blog

Here we share some thoughts, insights and ideas related to Human Factors Training

Sharing best practice

I spent some time in a major NHS Trust the other week, delivering two days of training at a large hospital.

The training involved very senior management, and I took the opportunity to mention the recurring incident which involves two syringes of colourless medicines being mixed up on the scrub tray.

I asked the senior management in the room, "So how do you do it here? Do you colour code the syringes, barcode them, or add labels?"

A senior nurse in the room spoke up, explaining she put Steristrips on each syringe and writes onto these. But there's no standard hospital protocol, designed to prevent the potentially severe mix-up from happening.

Sitting in the corner was the senior manager responsible for all elective surgery in this hospital. She sat there with her mouth open, realising there was no guideline in place designed to avoid or trap an easily preventable mistake.

I had an email exchange with her the following morning, and she confirmed she had a team working on the problem straight away.

What if I hadn't delivered training at that hospital? What if she hadn't attended the course that day?

Sharing best practice and national standards are sadly sorely lacking in the medical profession.

We're aware of another hospital, where recently an anaesthetist told me she administered a child with Adrenaline, not Fentanyl. This is important because Fentanyl is an opioid, slowing the heart rate. Adrenaline speeds it up.

Following the medication mix-up, the team were questioning why the child had become tachycardic, thinking something must have been seriously wrong with him. Only on return to the anaesthetic prep-room was the mix-up noticed.

Probable cause? Working with a new ODP, who drew up the drugs in an unfamiliar way and cross-checking was secondary to social team building.

Sharing best practice is so important. It is a shame that there is rarely time for medical professionals to spend a little time down the road with their colleagues at other hospitals, learning from the way they do things.

You attend a conference, and someone will often share best practice. But they tend to talk about their own hot topic, their specialist research area. It becomes hit and miss whether you attend relevant sessions.

There are locations around the country, and indeed around the world, that have solved significant issues. But sadly all too often others don't know about it.

This reminds me of the famous Donald Rumsfeld statement, about the 'known knowns' and 'unknown unknowns'.

Working out your unknown unknowns by sharing best practice between different teams is a really valuable but arguably essential step.

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Human Factors & Patient Safety Updates (Aug 2018)

Free conference for NHS staff this November

We're proud to be speaking alongside Roy Lilley, Cara Charles-Barks (Salisbury NHS), Dr Mohammad Al-Ubaydli, Mark Coooke (NHS England SW) & Dr Felix Jackson at this free to attend event on 6 November in Exeter. 

The future is uncertain. With the dawn of technology, will healthcare staff be usurped by advanced apps & artificial intelligence? What leadership strategies are in place to help NHS staff cope with the Salisbury Novichok incidents? How will joint working & mergers affect staff? 

This event explores Collaborative Networking - The Future Of Healthcare. This free conference brings you speakers from a wide spectrum of specialties. We aim to inspire & teach NHS staff from all departments as well as patients on how to adapt to systems change in a way that brings about efficiency & value. Addressing two of the fundamental themes of Future Focused Finance.

Find out more here & don't forget to follow the event organisers @nhsFFF on Twitter

Fixing a System Under Pressure

Everyone seems to say now that they have a 'Learning Culture' - but what is your SOURCE of Learning? 

The British Medical Association has recently shared some of the footage from The Future Vision for the NHS workshop ran last month. On the day around 50 members from across different parts of the medical profession came together to contribute ideas, experiences and examples to help inform the BMA's work to press for change in the NHS.

Watch a selection of videos from the event here, including 'Fixing a System Under Pressure' a short presentation from Atrainability.


Excellent Feedback from Serious Hazards of Transfusion Conference


​We were recently sent the official feedback from the SHOT blood service conference we spoke at in July. 

This year saw record numbers of delegates, which could be partly attributable to having more international delegates from the IHN meeting. 

There were 270 online submissions for the evaluation survey, which was a response rate of 85.7% (the evaluation survey was sent to 315 individuals, excluding exhibitors). 

Trevor Dale spoke at the conference about Walking the Tightrope.

The feedback on the conference was exceptionally positive, and we were very happy to receive top scores on most informative and best performance of the speakers.


Who's tweeting Human Factors...

One to follow: #learnnotblame is the fantastic campaign lead by Dr Cicely Cunningham launched by The Doctors Association UK, we'll definitely be following and supporting her progress as she raises important issues that's relevant to Human Factors values.

That's our round up of the updates from us for now, please get in touch and let's see how we can help your teams.

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