Derek Malyon

Dear Patient Safety Learning,

Inadvertent administration of an oral liquid medicine

into a vein (12017/009) HSIB.

This HSIB report has missed a massive industrial H&S faux-par 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This HSIB report (12017/009 ) should be withdrawn and updated.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 Wexner 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".

Ward-Patient Safety Solution HSIB 14.1.2021..pdf

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 Everyday 2.6m/365 customers killed across this outdated healthcare sector without human error recovery protocols and the klaxon.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

Dear Steve Turner.

[Charlotte Leslie MP: "My Father is a Doctor and it is known if you lift your head above the parapet you can expect not to have a job the next day." (Recorded and paraphrased from Radio 5 live interview).

Now, I am about to blow your socks off Steve.

I posted an article in "Communities" you should read "Ward-patient eQMS ...." 24.11.2020.

End WB with an Industrial H&S  error recovery protocol combined with an eQMS. 

WB's doing the right thing solved with software and patient tagging acknowledgement of interventions.

I would really appreciate your response.

Derek Malyon.

Overview

Human error (HE) in global medicine kills 2.6 million annually placing patient safety on the G20 Summit (1). Solutions available (a) more staff training dominated by a HE-rate of about one error in 200 tasks and (b) a simple computer system used by high reliability organisations such as Banking with zero HE.

With 70% of adverse events occurring on wards, patients should electronically acknowledge each intervention with their wristband-data. Missed interventions now detectable are compellingly alarmed reducing the consequences of HE 10,000 fold.

Problem: The Healthcare sector have no “HE Recovery Protocols” on their wards (2a)
This massive management error is punishable with fines and imprisonment across every other sector including Nuclear Rail Shipping etc. by the CPS here in the U.K.

HE recovery protocol for ward-patient safety

The patient is placed in a computerised quality-loop enabling them to acknowledge received MDT
interventions by tagging their personal wristband-data back to the computer care plan. Missed interventions easily detected by the software-checklist now compellingly alarmed on-screen in front of health worker and patient. Nigh impossible to ignore, missed interventions are corrected, reducing the consequences of HE by more than a factor of ten thousand (104) (2b).
 

Example: Opioid overdose prevention

Software analyses patient's analgesic ladder. Their previously tagged opioid consumption displayed with opioid headroom warning. The patient tags acknowledging and updating the new opioid volume correctly administered. The system would have saved 450 Gosport patients 30-years ago, and currently under live investigation by Police (Operation Magenta).

Conclusion

Placing the ward patient in a computer driven tagged quality loop significantly reduces HE-consequences improving compliance lowering death rates adverse events bed-days and litigation. The tag system has a long-standing pedigree too. U.K. Bank customers have electronically tagged 30 million times a day, keeping accounts healthy and error free for decades.

Please could colleagues on the hub help the NHS/CQC understand this established Industrial H&S concept with a view to trialling it. (Sums: 2.6m/10,000=2600 saving 2,597,400 annually?)

References:
[1] The cost of patient safety inaction: Why doing more of the … A .M. Alhawsawi. Patient Safety Hub 2020.
[2a] 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 74-75).
[2b] https://books.google.co.uk/ then type “1. compelling feedback ” (page 78-79). Compelling feedback reduces HE by
a factor of 10,000.
Foot note: Sometimes whole industries become unwilling to look too closely at system faults and the blame machine
swings into action. Pity the individual health worker not protected by management HE recovery
protocols. https://books.google.co.uk/ type “The blame machine preface xii” last two paragraphs and xiii.
Derek Malyon.
24.11.2020.

Ward-Patient eQMS with Error Recovery Protocols.3 pdf.pdf