NHD Episode 15 – Safety Too?

Welcome to No Harm Done Episode 15 hosted by Cathy Balding and Cathy Jones, from Melbourne, Australia.

In this episode we get proactive about Risk Management in RM Part 2 – ‘Safety 2’ – as our Quality Quandary and TLDR. What’s it all about? In Quality Hacks, Balding describes how to develop your story using the ‘Pixar Pitch’ and Jones has a gentle rant about email addresses. The Point considers consumer vulnerability. And more! What would you like us to talk about next? Send us a message below!

0.00 QUALITY QUANDARY: Safety 2. What is it – and why do you need to know?

Refs:

From Safety-I to Safety-II: A White Paper Professor Erik Hollnagel University of Southern Denmark, Institute for Regional Health Research (IRS), Denmark Center for Quality, Region of Southern Denmark Professor Robert L Wears University of Florida Health Science Center Jacksonville, United States of America

Paul Plsek, Understanding the System You Are in Is Key to Improving It    HealthcarePapers 17(1) July 2017 : 38-43.doi:10.12927/hcpap.2017.25335

Jeffcott SA, Ibrahim JE, Cameron PA
Resilience in healthcare and clinical handoverBMJ Quality & Safety 2009;18:256-260.

20:30 THE POINT:  How vulnerability changed the perspective of one nurse – and why knowing too much can make you feel more vulnerable – not less.

Ref: Schuler, M. (2019). Changing Roles, Changing Perspectives—Vulnerability as a Patient. Journal of Patient Experience, 6(1), 5–6. https://doi.org/10.1177/2374373518769662

26:27 TOO LONG DIDN’T READ (TLDR):  We deconstruct human factors as a key component of Safety 2.  There are a few TLDRs in this episode, all under the human factors umbrella.

Refs:

Russ AL, Fairbanks RJ, Karsh B, et al The science of human factors: separating fact from fiction. BMJ Qual Saf 2013;22:802-808.

Leape LL. Error in Medicine. JAMA. 1994;272(23):1851–1857. doi:10.1001/jama.1994.03520230061039

Doug Bonacum (IHI) Error Reduction – Hierarchy of Controls:

http://app.ihi.org/FacultyDocuments/Events/Event-2883/Presentation-15021/Document-11934/Presentation_3_2_Human_Factors.pdf

http://app.ihi.org/FacultyDocuments/Events/Event-2626/Presentation-11609/Document-9138/Presentation_2_2_Human_Factors_and_Technology_FF.pdf

50:31 QUALITY HACK:  In this episode we discuss how to create your Pixar Pitch – and why! Plus Jones’ beef about email addresses.

Ref: Pixar Pitch
http://www.workingdifferently.org/working-differently-blog/the-pixar-pitch-telling-your-story-crisply-and-with-clarity-in-order-to-compel-action