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Derek Malyon


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About Derek Malyon

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    Complete outsider: No healthcare training. Retired communications researcher (30+ publications). Our Research Department achieved BS 9001 quality accreditation . Bowel cancer survivor. Here is the rub: Patient safety errors in 4 out of 5 departments including incorrect chemo dosing, missing fluid intake prior to radiation doses, missing biopsy results. These innocent errors then cascade to further departments.
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  1. Content Article Comment
    Good evening Clive. Thank you for the information. I have already contacted AHSN via their website with limited word count and directly to their email address with pdf receiving their auto reply. Because the NHS culture is slow to change this eQMS derived from Industrial H&S and banking sectors will be a shock and problematic for William Lilley. So, I have decided to send William a copy to digest for Christmas entertainment. Ho Ho Ho. The first objective is that AHSN fully understand the concept of an "eQMS with an Alarmed Error Recovery Protocol". This is crucial. If they wish to progress the idea perhaps they should choose how to implement the trial. I have no healthcare experience what so ever. I appreciate your interest Clive. Kind Regards Derek
  2. Content Article Comment
    Hi Clive Thank you for eight good questions. I think the 311 word body in the pdf answers some of these (Qu.2, 6). It is purposely brief admittedly. Qu.3 Since the patient must be conscious and capable of understanding yes and no obviously the solution is not suitable for maternity, young children and the operating theatre. However, these patients can have a substitute tag from two different health workers. HE consequences reduced only by a factor of 1000 (Ref. 2a in download.). Steve Turner (community nurse) also sees possibilities too. QU.4, 5, 6 7. I believe "An eQMS with Alarmed Error Recovery Protocols" is a first in global healthcare but common in banking and parcel delivery where the customer is placed in a computerised quality loop. If we kill the AE's as this system can, and not 2.6M patients globally, cost savings are humungous Ref.1 in the download. QU.8 Our NHS should assess this eQMS with a view to trialling it. Thank you Clive for allowing me a platform. Derek. Ward-Patient Safety Solution. An eQMS with Alarmed Error RecoveryProtocols..pdf
  3. Content Article Comment
    Hi Clive Thank you very much for the information. I contacted the SW AHSN Tuesday 11.2.2020. Here is a copy sent sent now. Hello AHSN I contacted you in Feb 2020 but received no reply. Clive Flashman of the Patient Safety Learning hub suggests I contact you. I wish to send you a pdf (1.7 Mbit): Ward-Patient Safety Solution: An eQMS with Alarmed Error Recovery Protocols. This ward-patient tagged quality system reduces healthcare worker HE consequences by a factor of 10,000. It is a derivative of industrial H&S and the Banking sectors. Kind Regards Derek. ------------------------------------------------------- Thank you Clive. Kind Regards Derek (Torquay. Devon.)
  4. Content Article Comment
    Hi Swoo. I only received downloads. No comments received. Did you want to provide a typical ward issue and solve it with an eQMS? If so, I present ward case file 3. paraphrased from 540-170 words from this download. .Human-Factors-How-to-Guide-v1.2 (14).pdf A nurse was in charge of the night shift with an agency nurse on duty with her. A heparin infusion needed replacing. The nurse partly drew up the infusion but was distracted coming back latter to find it missing and told by agency nurse it was administered to the patient. The dose was corrected and no harm came to the patient. When the Ward Sister arrived, the nurse discussed what had happened. The following day the nurse received a call at home to say the senior nurse wanted to take the matter further, there would be an investigation and she was suspended from drug administration until a formal disciplinary hearing had taken place. At the hearing she was reprimanded for failing to follow protocol by not immediately completing an incident form and failing to better supervise the colleague who had administered the drug. She was given an oral warning to be kept on record for six months and required to be reassessed on drug administration. Five weeks later, the nurse resigned. eQMS solution. (1) Use barcoded manufactured drugs sized for the job. (2) Nurse and patient log-on with their wrist data. Medicine barcode scanned. That's about it. The computer software checklist does the hard work. If any error occurs the hooter alarms, nurse corrects error in-front of patient. Please get back to me if other ward issues are getting difficult to prevent. Thank you for your question. Derek.
  5. Content Article Comment
    Dear Helen Thank you so much for replying. I believe this solution is completely new to healthcare. I have contacted countless NHS departments as well as Sir Robert Francis QC, Professor Carl Macrae, Professor C P Gale, the BMJ and WHO. All seem lost. In the U.K. this technique would have saved 33,000 heart attack and 60,000 bedside life-sign patients in a 10-year period. Please can the hub help me find an NHS Department who will pickup this patient safety eQMS. Perhaps Dr Abdulelah Alhawsawi would be interested? (I have no connection with the NHS at all.) Many Thanks Derek.
  6. Content Article Comment
    Dear Helen Hughes CE. Please find enclosed pdf "Ward patient safety solution: An eQMS with Alarmed Error Recovery Protocols." It is one hell of a technique, Steve Turner gives it the thumbs up too. This is the global silver bullet you and PSL have been waiting for. If there is anything you do not understand please contact me. Kind Regards Derek. Ward-Patient Safety Solution. An eQMS with Alarmed Error RecoveryProtocols..pdf
  7. Content Article Comment
    Hi I have a download problem with this article. Hope this helps. Derek.
  8. Content Article Comment
    Hi Colleagues This paper just muddies the water and typical of many trying to find inspiration from other sectors to the health sector. Bottom line: Detect the error and compellingly alarm. Check out solution: Ward-Patient eQMS with Error Recovery Protocols.4.pdf Thank you for your attention. Derek Malyon.
  9. Content Article Comment
    Ward-Patient eQMS with Error Recovery Protocols.4.pdf Dear Claire Thank you for posting this article. On page 5: The right medicine for the right patient and the right time. Fine words but where is the solution. There is no mention of error recovery protocols, compelling alarms reducing error by a factor of 10,000 or a quality management system which includes acknowledgement by the patient receiving the correct barcode read medicine against the care-plan software checklist. This is standard industrial H&S. Umpteen NHS departments over the years have no idea of what I am talking about. One shining light is PSL Leader Steve Turner. Kill the AE's not 2.6 million patients annually. Wake up NHS this is your chance to trial a world beating eQMS protecting patient healthcare worker and reducing error to the point WB is not needed just a software tweek. Kindest Regards Derek. Using this system injecting swab into the patient is impossible. (Indistinct chlorohexidine Rob Hackett).
  10. Content Article Comment
    What an important subject. No comments and no solutions from readers. "Antiseptic solution injected into her epidural." On inspection these medicines etc. have a barcode differentiating them. The patient's care plan shows on-screen in front of health worker and patient the allowable medicines for epidural. In error the antiseptic barcode read and error detected using the software-checklist then alarmed. The consequences of the human error reduced 10,000 fold. Check out: Ward-Patient eQMS with Error Recovery Protocols.4.pdf
  11. Content Article Comment
    Hi Patient Safety (grim statistics): The healthcare sector with no human error recovery protocols kills 2.6m annually. Read my post to reduce human error 10,000 fold like every other sector except yours. Ward-Patient eQMS with Error Recovery Protocols.4.pdf
  12. Content Article Comment
    Dear Hugh You may be interested in a ward-patient safety QMS which reduces human error consequences 10,000 fold. The implication being a significant reduction in AE, deaths litigation and the need for WBs. Kind Regards Derek Malyon. Ward-Patient eQMS with Error Recovery Protocols.4.pdf
  13. Content Article Comment
    Hi Swoo Thank you for the downloads implying the patient is protected from incorrect medicine and volume as displayed in the gallery. Is my assumption correct. Thank you for your post. Kind Regards Derek.
  14. Community Post
    Hello Steve Thank you so much for your two replies. Your understanding is spot on. This ends an 11-year journey of countless letters and emails to numerous NHS departments that stonewall. The Industrial H&S concept of (a) detect error and (b) alarm, is fundamental across all sectors. The health sector high on learning and countless articles need to come down to earth and copy the solution adopted some 30 or 40-years ago with the introduction of the micro in the 80's. The patient safety leads really need to get to grips with this Patient Safety and WB Solution. Everyday 2.6m/365 customers killed across this outdated healthcare sector without human error recovery protocols and the klaxon. Thank you so much Steve. Kind Regards Derek Malyon
  15. Content Article Comment
    I have no healthcare experience but would like to respond from an Industrial H&S and QMS background. While your medicines all look the same, their barcode differentiates. Scanning the barcode into the patient's care plan enables the software checklist to detect the error. Having detected the medicine error and volume the computer alarms in front of healthcare worker and patient. Impossible to ignore the error is corrected. Error is reduced by a factor of 10,000. More information at posting " Ward-patient eQMS with error recovery protocols..." Kind Regards Derek Malyon.