Derek Malyon

Dear Helen Hughes, Steve Turner and Clive Flashman.

Re: Patient Safety QMS with Alarmed Error Recovery.

Method: The patient uses their wristband barcode to acknowledge every intervention against their MDT software checklist.

Except for CQC and Sir Robert Francis, most NHS front offices including digital find excuses and ignore the safety solution not passing the proposal up.

The Wexner Medical Centre used the technique by comparing the medicine barcode with a software checklist alarming an error in front of nurse. A reduction in errors was achieved.

Effect of Barcode-assisted Medication Administration on Emergency Department Medication Errors: J. Bonkowski et al. AEM Vol. 20.8: p801-806: 2013. (Method: page 802, 2nd column, "Medication administration with BCMA................. an alert notified the nurse of a potential for error".

https://onlinelibrary.wiley.com/doi/epdf/10.1111/acem.12189

So, the latest rejection by AHSN and HSIB's deputy medical director is unbelievable.

Any business in any other Sector which kills a worker, customer (patient) or member of the public face corporate manslaughter charges by the Police and Crown Prosecution Service here in the UK. The HSIB deputy medical director needs to reconsider their position and apologise.

Police Operation-Magenta with 100 detectives is the 4^th attempt to investigate 450 opioid overdose deaths at GWMH. They need our help desperately. The global healthcare Sector essentially have no error recovery protocol on wards. This is the primary cause of 2.6-4.8 million unnecessary deaths globally and an annual pandemic. Managers who do not respond to this classic industrial H&S solution will very likely have their collars felt by Police.

Would PSL be prepared to inform NHS England and other patient safety forums of the solution and promote the Operation Magenta website.

Thank you so much for your platform.

Kindest Regards

Derek.

Dear Helen Hughes, Steve Turner and Clive Flashman.

Re: Patient Safety QMS with Alarmed Error Recovery.

Method: The patient uses their wristband barcode to acknowledge every intervention against their MDT software checklist.

Except for CQC and Sir Robert Francis, most NHS front offices including digital find excuses and ignore the safety solution not passing the proposal up.

The Wexner Medical Centre used the technique by comparing the medicine barcode with a software checklist alarming an error in front of nurse. A reduction in errors was achieved.

Effect of Barcode-assisted Medication Administration on Emergency Department Medication Errors: J. Bonkowski et al. AEM Vol. 20.8: p801-806: 2013. (Method: page 802, 2nd column, "Medication administration with BCMA................. an alert notified the nurse of a potential for error".

https://onlinelibrary.wiley.com/doi/epdf/10.1111/acem.12189

So, the latest rejection by AHSN and HSIB's deputy medical director is unbelievable.

Any business in any other Sector which kills a worker, customer (patient) or member of the public face corporate manslaughter charges by the Police and Crown Prosecution Service here in the UK. The HSIB deputy medical director needs to reconsider their position and apologise.

Police Operation-Magenta with 100 detectives is the 4^th attempt to investigate 450 opioid overdose deaths at GWMH. They need our help desperately. The global healthcare Sector essentially have no error recovery protocol on wards. This is the primary cause of 2.6-4.8 million unnecessary deaths globally and an annual pandemic. Managers who do not respond to this classic industrial H&S solution will very likely have their collars felt by Police.

Would PSL be prepared to inform NHS England and other patient safety forums of the solution and promote the Operation Magenta website.

Thank you so much for your platform.

Kindest Regards

Derek.

Dear Patient Safety Learning,

Inadvertent administration of an oral liquid medicine

into a vein (12017/009) HSIB.

PSL over view: Healthcare Safety Investigation Branch (HSIB) report on the inadvertent administration of an oral liquid medicine into a vein. This report indicated the importance of using human factors in the investigation process. The investigation reviewed the effectiveness of the current processes for the storage of medicines, equipment design, and the prescribing, preparation, checking and administration of medication. It also considered the contextual, environmental and human factors that influenced the inadvertent administration of an oral solution into a vein. The effectiveness of current processes for implementation of local safety standards for invasive procedures was also considered. A human factors expert was involved in the investigation and a dedicated report was written based on the evidence reviewed, a reconstruction of the event and a simulation of what should have happened.

The global hospital latent-error: This HSIB report has missed a massive industrial faux-par and Ward-Patient Safety Solution HSIB 14.1.2021..pdfpartly responsible for 2.6 million unnecessary healthcare deaths annually in the Sector.

Hospital management has no “Alarmed Error Recovery Protocol (1)” preventing

medicine error, missed procedures and error cascade across departments.

This HSIB report (12017/009 ) should be withdrawn and updated. You can read the system-solution from the Wexler Medical Centre in reference (2) and enclosed PDF. Are there similar solutions here in the UK? The next HSIB report on paracetamol overdosing will almost certainly be read by Police Operation Magenta (450 opioid deaths).

Thank you.

Kind Regards

Derek.

References:

(1) The Blame Machine. R B Whittingham. ISBN 0-7506-5510-0.  Industrial H&S. https://books.google.co.uk/ then type “5.3 error recovery ” (page 74 to 79). Compelling feedback reduces HE consequences by a factor of 10,000+.

(2) Effect of Barcode-assisted Medication Administration on Emergency Department Medication Errors: J. Bonkowski et al. AEM Vol. 20.8: p801-806: 2013. (Method: pdf page 802, 2nd column, "Medication administration with BCMA................. an alert notified the nurse of a potential for error".

Hi Clive.

I have contacted southwest academic health safety network (swahsn) with the above pdf "Ward-Patient Safety Solution: An eQMS with Alarmed Error Recovery." Their front desk staff cannot draw a response from their directors for innovation or patient safety. I have also contacted WL by email  18/12/20, 7/1/21 and left a telephone message but receive no reply from him either.

------------------------------------------------------------------------------------------------------------

Good News: The reference below  (1) describes a similar healthcare quality control detecting medicine error with alarms at the point of delivery to the patient. Sadly, the reduction in medical error is small in comparison to the maximum achievable (10,000) but this paper from an American emergency department in 2013 is noteworthy because it aligns with the classic Industrial H&S error recovery protocol with compelling alarm described and referenced above. 

                                         -----------------------------------------------

So, by simply adding patient tagged acknowledgement to every intervention on the MDT software checklist be it medicine, biopsy count, bloods, vital life sign, reports or advice etc, it protects patient from error across every department. 

Reference:

(1)   Effect of Barcode-assisted Medication Administration on Emergency Department Medication Errors: J. Bonkowski et al. AEM Vol. 20.8: p801-806: 2013. (Method: p802, 2nd column, "Medication administration with BCMA................. an alert notified the nurse of a potential for error."(110 words).

Thank you.

Kindest Regards

Derek.

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

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

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.)

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.

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.

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

Hi 

I have a download problem with this article.

Hope this helps.

Derek.

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.

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).

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

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

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

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.

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.