Heather Gluyas

Effective communication and teamwork promotes patient safety

Teamwork requires co-operation, co-ordination and communication between members of a team to achieve desired outcomes. In industries with a high degree of risk, such as health care, effective teamwork has been shown to achieve team goals successfully and efficiently, with fewer errors. This article introduces behaviours that support communication, co-operation and co-ordination in teams. The central role of communication in enabling co-operation and co-ordination is explored. A human factors perspective is used to examine tools to improve communication and identify barriers to effective team communication in health care.

Patient-centred care: improving healthcare outcomes.

Patient-centred care is a model of care that respects the patients experience, values, needs and preferences in the planning, co-ordination and delivery of care. A central component of this model is a therapeutic relationship between the patient and the team of healthcare professionals. The implementation of a patient-centred care model has been shown to contribute to improved outcomes for patients, better use of resources, decreased costs and increased satisfaction with care. This article provides an overview of the barriers to providing patient-centred care and identifies strategies that can be implemented to overcome them.

Understanding situation awareness and its importance in patient safety.

Situation awareness describes an individuals perception, comprehension and subsequent projection of what is going on in the environment around them. The concept of situation awareness sits within the group of non-technical skills that include teamwork, communication and managing hierarchical lines of communication. The importance of non-technical skills has been recognised in safety-critical industries such as aviation, the military, nuclear, and oil and gas. However, health care has been slow to embrace the role of non-technical skills such as situation awareness in improving outcomes and minimising the risk of error. This article explores the concept of situation awareness and the cognitive processes involved in maintaining it. In addition, factors that lead to a loss of situation awareness and strategies to improve situation awareness are discussed.

Human factors and medication errors: a case study.

Human beings are error prone. A significant component of human error is flaws inherent in human cognitive processes, which are exacerbated by situations in which the individual making the error is distracted, stressed or overloaded, or does not have sufficient knowledge to undertake an action correctly. The scientific discipline of human factors deals with environmental, organisational and job factors, as well as human and individual characteristics, which influence behaviour at work in a way that potentially gives rise to human error. This article discusses how cognitive processing is related to medication errors. The case of a coronial inquest into the death of a nursing home resident is used to highlight the way people think and process information, and how such thinking and processing may lead to medication errors.

Errors in the nursing management of a deteriorating patient

Effective management of the deteriorating patient requires early recognition of the signs of deterioration, timely review and appropriate interventions. However, this does not always occur. Errors in the recognition and management of a deteriorating patient are rarely related to a single factor; rather they are a complex interaction of system and human factors. This article presents a case study focusing on understanding the factors that led to errors resulting in the death of a patient. Understanding the complex interaction of system and human factors enables the identification of strategies that could be used to decrease the likelihood of a similar incident occurring.

Understanding the human and system factors involved in medication errors

Medication errors involving patients are a serious concern in healthcare practice. Nurses, more than any other healthcare professional group, are principally involved in medicines administration. This article recognises the complexity of why medication errors occur and considers the many factors involved, including those from an individual and organisational system perspective. It adopts a solution-focused approach, based on the evidence underpinning the knowledge of medication errors.

Human factors and the death of a child in hospital: a case review.

Learning from adverse events and errors is important if systems and processes are to be improved and to minimise the likelihood of similar events in the future. This article uses the report from a coroners inquest into the death of a seven-year-old child in hospital to examine errors that contributed to the childs death. These errors are reviewed from a human factors perspective. The article provides an overview of error causation concepts and offers strategies that healthcare organisations can implement to reduce the incidence of such errors.