CHIRP - Confidential Human factors Incident Reporting Programme

[Madbob]

Well, I've been out of the RAF since 1989 but even then CHIRP had been invented and I see from their website today that it is still around and that as well as aviation it covers maritime as well. www.chirp.co.uk (http://www.chirp.co.uk)

The recollection I had then was that it was an excellent medium for reporting "holes in the cheese" and covered aircrew, engineering, ATC et al and was widely used.

The question I have is ought not a similar scheme be set up to include the NHS in the light of the recent scandal affecting the Mid Staffs NHS Trust? A few blows on the whistle in good time might have prevented this (and other) tragedies.


It also had me thinking that an annual AOC-type inspection for NHS hospitals might not be a bad idea too!

MB

[Fox3WheresMyBanana]

Interesting that the NHS has also picked upon the ginger beers' methods of 'tool' control for operating theatres.
The docs in Canada now do the equivalent of out briefs, where they check with the patient before they are put under. Stuff like "You are expecting to get your left leg amputated below the knee, correct?"

Mind you, the Uni I worked at had all the correct procedures for emergency reviews. They put me in charge of a building. I was given a full briefing and a file on the evacuation procedures. They did an annual drill, monthly safety meetings, blah. All seemed good. I sent out memos. No response. I got off my backside and went to talk to the people on the lists. Couldn't find them, most away from the site regularly. I asked their minions "Does the drill work?" "No" "Has it ever worked?" "No"

Absolutely no reporting system is going to make up for management that doesn't give a toss.

Our top priority is .... a comfy job with no aggro from the little people.

[Dave Clarke Fife]

A friend of mine has been involved with implementing just such a checklist type system for the medical profession. Can only be a good thing in my very humble opinion.



Med Safety - Our Consultants and Associates (http://www.medsafety.co.uk/our-consultants-and-associates/)

[Pontius Navigator]

went to talk to the people on the lists. Couldn't find them, most away from the site regularly.

Similar, when I took up appoints as an operations officer etc one of the first things was to go through the lists to see if the people existed and phone numbers worked.

I would then work through all the manuals to see if they were active and being managed or simply door stops.

I suspect the problem at the NHS started with budget cuts, reducing workers (nurses) which then removed the flexibility to think and act. Then modernisation with that inexorable waster of time - the computer which demands a regular dose of data.

Mrs PN, a retired nurse, with her sister, also a nurse, and SiL a radiographer, nursed her father while he was being generally left to his own devices in the ward. When he died they offered her a job. She declined saying that they would not tolerate her insistence on proper nursing rather than the degree cr*p you get now.

[Fox3WheresMyBanana]

I'm particularly interested in why Service personnel are so good at this stuff, and other professions (e.g. education, medicine) aren't.

I've helped a couple of colleagues get their MEd's. Their bookwork was mostly PC rubbish (especially the leadership bit). The procedures stuff included nothing on the nuts and bolts of how to actually set up a procedure. The feedback was usually from an academic who'd never done it.
My BiL (accountant) recently worked for a Uni Business School. He was hired because they couldn't balance their books.

I think the best start we got was IOT. Firstly, we actually took actions and worked through procedures in the office simulator. Secondly, those exercises were designed to show up potential faults in procedures. Lastly, the debriefs were frank and open.
Thoughts?

[Sideshow Bob]

When I attended my CRMi course, half of the 12 students were from the NHS. Ever since the Elaine Bromiley case, where her Husband Martin (a pilot) insisted that the Human Factors involved be examined and a way be found to educate staff so the same mistakes would not be made again, the NHS has been investing in training. Unfortunately it is down to each trust to decide just how much they invest.
From speaking to those involved, as with the introduction of CRM/Human Factors in aviation, the biggest stumbling block has been the old and the bold (senior surgeons who believe using a check list is a sign of weakness and an affront to their ability)