Tag Archives: patient safety

Taking Human Factors to the top of the NHS

Posted by Luigi Fort, Senior Marketing Executive

The Clinical Human Factors Group are taking the human factors message to top-level NHS management at their Safety Science & Solutions conference next week (Birmingham, UK, 12 March 2014). This is particularly timely bearing in mind the National Quality Board’s recent Concordat which aims to embed Human Factors principles and practices into the healthcare system.

The conference will enable Chairs, Chief Executives, Executive and Non-Executive Directors, Chief Operating Officers, Directors of Nursing, Medical Directors and Divisional Managers, Lead Clinicians to gain insights that will positively impact their role in promoting safety, quality and productivity in healthcare.

Ashgate publishes a range of books relating to Human Factors in Healthcare and Patient Safety. Why not take a look on our website?

James Reason’s new book “A Life in Error: from little slips to big disasters”

‘This book is like a personal and intimate trip through the ideas that pioneered human error and industrial safety. It goes into day-to-day experience of errors, contains testimonials and anecdotal information, and widens to system safety. Everything seems to have been said on the topic, and yet the book puts the matter differently in a manner that is true, full and in plain, jargon-free language. I love this book.’    René Amalberti, Haute Autorité de Santé, France

‘Reason’s new book is a master class on human error: a concise tour of his career explaining how mistakes can occur. It is a pleasure to accompany him while he presents his favourite and often funny accounts of fallibility, tempered with insights on the resulting risks and how they can be mitigated.’   Rhona Flin, University of Aberdeen, UK

From James Reason’s introductory note to his new book A Life in Error:

A Life in ErrorThis short book covers the main way stations on my 40-year journey in pursuit of the nature and varieties of human error. Inevitably they represent a very personal perspective, but I have also sought to include contrary opinions.

The journey, as at this point, begins with a bizarre, absent-minded action slip committed by me in the early 1970s—putting cat food into the teapot— and continues until the present with a variety of major accidents that have shaped my thinking about unsafe acts and latent conditions.

The original focus of this enquiry was individual cognitive psychology, but over the years the scope has gradually widened to embrace social, organizational and systemic issues. For the most part, my interest here is more on the journey than on the details of each waypoint—though there will be some exceptions. There are two reasons for this. First, many of the waypoints have been covered in previous Ashgate books. Second, I want to focus on the factors either in my head or in the world that prompted the next step in the journey.

This book is written for all those who have an interest in human factors and their interactions with the workings of technological systems whose occasional breakdowns can cause serious damage to people, assets and the environment. This is a large and diverse group whose number, I hope, includes students, academics and safety professionals of all kinds—and has lately included a growing number of health carers. Where possible, I have tried to make clear the thinking and—if you’ll excuse the unavoidable pun—the reasoning that contributed to the models, metaphors, taxonomies and practices that have influenced the course of this journey.

This succinct but absorbing book covers the main way stations on James Reason’s 40-year journey in pursuit of the nature and varieties of human error. A Life in Error charts the development of his seminal and hugely influential work from its original focus into individual cognitive psychology through the broadening of scope to embrace social, organizational and systemic issues. The voyage recounted is both hugely entertaining and educational, imparting a real sense of how James Reason’s ground-breaking theories changed the way we think about human error, and why he is held in such esteem around the world wherever humans interact with technological systems.

About the Author: James Reason has written books on motion sickness, absent-mindedness, human error, aviation human factors, managing the risks of organizational accidents, managing maintenance errors, and the human contribution: unsafe acts, accidents and heroic recoveries. He has worked in a wide variety of hazardous industries, though patient safety is now his primary concern. In 2003, he was awarded an honorary DSc by the University of Aberdeen. He is a Fellow of the British Psychological Society, the Royal Aeronautical Society, the British Academy and the Royal College of General Practitioners. He received a CBE in 2003 for his services to reducing the risks in health care. In 2010, he received an Award for Distinguished Service from the Royal Society for the Prevention of Accidents, and in 2011 was elected an honorary fellow of the Safety and Reliability Society.

‘This book is an authoritative reminder of the journey to gain acceptance of human error as intrinsic to open systems operations as we enjoy it today, portrayed by the witty pen of one of its topmost trailblazers. I thoroughly enjoyed the book, and found the segment on organizational accidents a particular gem.’   Daniel E. Maurino, formerly Coordinator of the Flight Safety and Human Factors Study Programme, International Civil Aviation Organization (ICAO)

‘A fascinating personal and intellectual journey showing the evolution of both James Reason’s personal approach and also the broader history of thinking on error and safety. He has a unique gift for making complex ideas accessible within an absorbing and lucid narrative. And all leavened with wonderful examples of human error and some great stories.’   Charles Vincent, Imperial College London, UK

 ‘Each chapter of this book tells a story where Reason personally confronted a puzzle about accidents, human performance, or organizational decisions. Together the stories build a comprehensive picture of how safety is created but sometime undermined.’   David D. Woods, Ohio State University, USA

‘In this delightful memoir, Jim Reason provides an amazingly comprehensive and understandable explanation of how and why individuals and organizations make mistakes and what to do about it. A valuable review for experts and a perfect introduction for beginners.’   Lucian Leape, Harvard University, USA

More information about A Life in Error: From little slips to big disasters

It seems ironic that patients and first responders should suffer injuries en route to treatment

Posted by Luigi Fort, Senior Marketing Executive

‘It seems ironic that patients and first responders should suffer injuries en route to treatment.’

So says (the late) Robert L. Helmreich in the foreword to the new book, Safety and Quality in Medical Transport Systems. He continues:

‘I became aware of the pressure to take risks while transporting patients when I was asked by an organization concerned about its accident rate to analyze causal factors in MedEvac helicopter crashes. Analysis of accidents revealed contributing pressures, including the severity of injury and the youth of the patient as well as weather, night operations, and obstructions to flight.’

To counter such pressures it is essential to develop the right kind of culture within the organizations that provide this vital service. CAMTS (The Commission on Acccreditation of Medical Transport Systems) recognize this and have brought together this reference book to support such organizations in providing the necessary culture. This is an environment that supports risk assessment, accountability, professionalism and organizational dynamics.

Safety and Quality in Medical Transport SystemsSafety and Quality in Medical Transport Systems: Creating an Effective Culture is edited by John W. Overton, Jr. and Eileen Frazer, Commission on Accreditation of Medical Transport Systems, USA

Contributors: Ralph N. Rogers; K. Scott Griffith; Terry L. von Thaden; Clive Adams; Nadine Levick; Kimberly Turner; Bruce A. Tesmer; Robin Graham; Terry Palmer; Roger Coleman; Gregory H. Botz; John W. Crommett; Melissa M. Mallis; John W. Overton Jr; Laurie Shiparski; Philip D. Authier; Eileen Frazer; Donna York Clark; Kate Moore; David F.E. Stuhlmiller; Jacqueline Stocking; Jennifer Hardcastle; Sandra Kinkade Hutton; Patricia Corbett; Dawn M. Mancuso; Kenneth P. Neubauer; David P. Thomson.

Risky Business 2010 – a successful conference for Ashgate

Posted by Luigi Fort, Senior Marketing Executive – Human Factors and Aviation

With the number of Ashgate books sold at the Risky Business 2010 Conference (Kings Place, London 18-19 November 2010) up by over 20%, Ashgate Publishing is establishing itself as a key publisher for healthcare and patient safety sector. Visitors seem to appreciate the significance of non-techncial skills as an aid to performance and service. This is reflected in the book sales with both Safety at the Sharp End and Safer Surgery doing extremely well. The Human Contribution, The Field Guide Understanding Human Error and The ETTO Principle: Efficiency-Thoroughness Trade-Off proved top-sellers too.

The top five:

Safety at the Sharp End: A Guide to Non-Technical Skills   Rhona Flin, University of Aberdeen, UK, Paul O’Connor, USA and Margaret Crichton, People Factor Consultants Ltd, UK

The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries   James Reason, Professor Emeritus, The University of Manchester, UK

The Field Guide to Understanding Human Error   Sidney Dekker, Lund University, Sweden

The ETTO Principle: Efficiency-Thoroughness Trade-Off: Why Things That Go Right Sometimes Go Wrong   Erik Hollnagel, MINES ParisTech, France

Safer Surgery: Analysing Behaviour in the Operating Theatre   Edited by Rhona Flin, University of Aberdeen, UK and Lucy Mitchell, University of Aberdeen, UK

Nordic Patient Safety Conference, 20-21 May – Stockholm

Guy Loft, Ashgate’s Senior Commissioning Editor for Human Factors, will be attending the 1st Nordic Patient Safety Conference, which is taking place in Stockholm, 20-21 May 2010.

If you will be there, do visit the Ashgate stand, to say hello and to browse through a selection of our books.

From the conference website:

Patient Safety Challenges is the theme for this Nordic Conference arranged by KTH. The aim of the conference is to inspire safety work within the health-care sector by presenting current safety research from a systems perspective. Leading and internationally renowned researchers, with experience from the health-care sector and other areas with high safety demands, will participate.

Exchange of information on patient safety issues, is another important aim of the conference. Rapid technological development, and changes in the health-care organizations under economical pressure, creates new risks in the medical sector. These risks need to be handled at all levels of the health-care system. Therefore, this conference is geared towards politicians and decision makers within the health-care sector, as well as representatives from academia in the Nordic Region.


Human Factors and Ergonomics Society meeting, 19-23 October, Texas

Guy Loft, Ashgate’s Senior Commissioning Editor for Aviation and Human Factors, will be attending the Human Factors and Ergonomics Society‘s 2009 meeting, 19-23 October 2009, in San Antonio, Texas.

From the HFES website:

The technical program includes research and applications work on a wide range of HF/E topics, including patient safety, driver distraction, and much more. Continue reading

Safer surgery

A recent House of Commons Health Committee recent ‘Patient Safety’ Report calls for improved undergraduate training in non-technical skills.

‘The NHS lags unacceptably behind other safety-critical industries such as aviation, in recognising the importance of effective teamworking and other non-technical skills.’

‘Patient safety must be fully and explicitly integrated into the education and training curricula of all healthcare workers. In addition, there must be more interdisciplinary training: those who work together should train together.’

In this context the new book Safer Surgery, edited by Rhona Flin and Lucy Mitchell, could not be more pertinent. It collates research by psychologists, surgeons and anaesthetists into how medical professionals work with each other in the operating theatre.  With a focus on observing and measuring the behaviour of operating team members, Safer Surgery explains methods and options for training in non-technical skills in the operating theatre environment.

This week (21-27 September) is Patient Safety First week – for more information visit the Patient Safety First website.