{"title":"Identifying resilience: a system safety review of trauma and orthopaedic theatres.","authors":"Victoria E Wills","doi":"10.1080/00140139.2024.2343930","DOIUrl":null,"url":null,"abstract":"<p><p>A prospective, qualitative study, of trauma and orthopaedic theatres was undertaken using the CARe QI handbook and the SEIPS framework, with the aim of preventing future Never Events. The study demonstrated a new approach, focussed on understanding 'work as done' to identify opportunities to improve system resilience, tested, using the Model for Improvement. Undertaken during the Covid-19 pandemic, it demonstrates that such conditions should not be a deterrent to observational studies, but requiring greater time and resource than a standard investigation, the approach may not align with current organisational or regulatory expectations. At the conclusion of this study, the mean time between Never Events in theatres had increased from 46 to 224 days, an achievement that had not previously been possible using the regulatory required, safety I, investigatory approach. These findings should be used to inform future PSIRF and Never Event Frameworks, to ensure effective systems-based analysis and improvement.</p>","PeriodicalId":50503,"journal":{"name":"Ergonomics","volume":null,"pages":null},"PeriodicalIF":2.0000,"publicationDate":"2024-08-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Ergonomics","FirstCategoryId":"5","ListUrlMain":"https://doi.org/10.1080/00140139.2024.2343930","RegionNum":3,"RegionCategory":"工程技术","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"ENGINEERING, INDUSTRIAL","Score":null,"Total":0}
引用次数: 0
Abstract
A prospective, qualitative study, of trauma and orthopaedic theatres was undertaken using the CARe QI handbook and the SEIPS framework, with the aim of preventing future Never Events. The study demonstrated a new approach, focussed on understanding 'work as done' to identify opportunities to improve system resilience, tested, using the Model for Improvement. Undertaken during the Covid-19 pandemic, it demonstrates that such conditions should not be a deterrent to observational studies, but requiring greater time and resource than a standard investigation, the approach may not align with current organisational or regulatory expectations. At the conclusion of this study, the mean time between Never Events in theatres had increased from 46 to 224 days, an achievement that had not previously been possible using the regulatory required, safety I, investigatory approach. These findings should be used to inform future PSIRF and Never Event Frameworks, to ensure effective systems-based analysis and improvement.
期刊介绍:
Ergonomics, also known as human factors, is the scientific discipline that seeks to understand and improve human interactions with products, equipment, environments and systems. Drawing upon human biology, psychology, engineering and design, Ergonomics aims to develop and apply knowledge and techniques to optimise system performance, whilst protecting the health, safety and well-being of individuals involved. The attention of ergonomics extends across work, leisure and other aspects of our daily lives.
The journal Ergonomics is an international refereed publication, with a 60 year tradition of disseminating high quality research. Original submissions, both theoretical and applied, are invited from across the subject, including physical, cognitive, organisational and environmental ergonomics. Papers reporting the findings of research from cognate disciplines are also welcome, where these contribute to understanding equipment, tasks, jobs, systems and environments and the corresponding needs, abilities and limitations of people.
All published research articles in this journal have undergone rigorous peer review, based on initial editor screening and anonymous refereeing by independent expert referees.