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Showing results for tags 'Human error'.
Found 272 results
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Content ArticleArterial lines are routinely fitted for severely ill patients in critical care and are flushed with a solution to maintain patency, and ensure that blood does not clot in the line. Saline is recommended as the flush solution for arterial lines. There are several examples of glucose solutions being inadvertently and incorrectly used to flush arterial lines. This has lead to inaccuracies in blood glucose measurements, which resulted in unnecessary administration of insulin and subsequent cases of hypoglycaemia, some of which have been fatal.
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Content ArticleIn 2008, the UK National Patient Safety Agency (NPSA) made recommendations for safe arterial line management. Following a patient safety incident in their intensive care unit (ICU), Leslie et al. surveyed current practice in arterial line management and determined whether these recommendations had been adopted. They contacted all 241 adult ICUs in the UK; 228 (94.6%) completed the survey. Some NPSA recommendations have been widely implemented – use of sodium chloride 0.9% as flush fluid, two‐person checking of fluids before use – and their practice was consistent. Others have been incompletely implemented and many areas of practice (prescription of fluids, two‐person checking at shift changes, use of opaque pressure bags, arterial sampling technique) were highly variable. More importantly, the use of the wrong fluid as an arterial flush was reported by 30% of respondents for ICU practice, and a further 30% for practice elsewhere in the hospital. This survey provides evidence of continuing risk to patients.
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Content ArticlePatient safety is often compromised by confusion over the graphic information on drugs packaging. Injectable medicines are particularly susceptible to medical error. This study gives design guidance to make such packs safer.
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Content ArticleHospital Watchdog is a nonprofit patient advocacy organisation in the US that champions safe hospital care for patients. They are a diverse group that includes nurses, physicians, pharmacists, healthcare experts, attorneys and members of the public. Some of them have experienced or witnessed medical errors that led to an extremely serious or tragic outcome. They are committed to improving unsafe conditions in hospitals. In February 2019, Hospital Watchdog conducted an in-depth interview with Ms. Dena Royal, a former paramedic, and respiratory therapist. Dena’s mother, Martha Wright, bled to death following a colonoscopy and a series of tragic nursing mistakes at Cass Regional Medical Center in Harrisonville Missouri.
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Content ArticleWhen Julie Bailey took her mother, Bella, into Mid Staffs Hospital in September 2007 she had no idea that her life was about to change forever. Over the next eight weeks she would witness such shocking neglect and abuse of elderly, vulnerable patients that the memories would haunt her for the rest of her life. And over the next five years she would uncover a culture of deceit and denial going right to the top of the NHS. From Ward to Whitehall is the story of Julie s fight for the truth to be uncovered about the deadly failings at Mid Staffs Hospital and her struggle to ensure that the tragedy would never be repeated.
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Content ArticleRecently, there have been a number of advances in technology, including in mobile devices, globalization of companies, display technologies and healthcare, all of which require significant input and evaluation from human factors specialists. Accordingly, this textbook has been completely updated, with some chapters folded into other chapters and new chapters added where needed. The text continues to fill the need for a textbook that bridges the gap between the conceptual and empirical foundations of the field.
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Content ArticleWhen faced with a ‘human error’ problem, you may be tempted to ask 'Why didn’t these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable people in it.
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Content ArticleIncreased concern for patient safety has put the issue at the top of the agenda of practitioners, hospitals, and even governments. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. Yet the discourse is often oversimplified and underdeveloped. Written from a scientific, human factors perspective, Patient Safety: A Human Factors Approach delineates a method that can enlighten and clarify this discourse as well as put us on a better path to correcting the issues.
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Content ArticleEvery clinical laboratory devotes considerable resources to Quality Control (QC). Recently, the advent of concepts such as Analytical Goals, Biological Variation, Six Sigma and Risk Management have generated a renewed interest in the way to perform QC. The objective of this book is to propose a roadmap for the application of an integrated QC protocol that ensures the safety of patient results in the everyday lab routine.
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Content Article
Patient Safety: 20 Years After “To Err is Human” (2019)
PatientSafetyLearning Team posted an article in Culture
In this US based eMagazine Patient Safety: 20 Years after ‘To Err is Human,’ sees thought leaders from across the healthcare industry examine how shifting to patient-centred care has helped organisations across the country sustain a deeper culture of patient safety. By implementing strategies such as optimising health IT usability, advocating on behalf of patients and supporting healthcare workers, patient safety continues trending upward, leading to better outcomes. -
Content ArticleThis report was prepared for the World Health Organization (WHO) Patient Safety’s Methods and Measures for Patient Safety Working Group.
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Content ArticleThe human element can give us kindness and compassion; it can also give us what we don't want — mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
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Content ArticleAccident investigations should consider why human failures occurred. Finding the underlying (or latent, root) causes is the key to preventing similar accidents.
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Content ArticleIn our previous blog we shared some reflections about the recent case of Dr Gawa-Barba and the implications the case has for the promotion of a learning culture in healthcare. In light of the Gawa-Barba case, the Government set up a review to which we have submitted a paper.
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Content Article
Reflecting on the Bawa-Garba case
PatientSafetyLearning Team posted an article in Legal matters
When an adverse event occurs in healthcare, the consequences can be catastrophic for patients and their families. In the aftermath of such events there are multiple needs, expectations and demands. This blog from our Patient Safety Learning website, looks at the case in which Dr Hadiza Doctor Bawa-Garba was convicted of manslaughter. -
Content ArticleOver the last two decades, safety improvements have flat-lined (as measured in fatalities and serious injury rates, for instance) despite a vast expansion of compliance and bureaucracy. The cost of compliance and bureaucracy can be mind-boggling – up to 10% of GDP, with every person working some 8 weeks per year just to cover the cost of compliance, paperwork and bureaucratic accountability demands. This is non-productive time. It has also stopped progressing safety.
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Content Article
An encounter with an error trap by Steve Highley (6 August 2015)
Sam posted an article in Error traps
Steve Highley looks at responding positively to error using a personal experience involving his car and highlights how to find and deal with error traps. -
Content ArticleIn these presentation slides, Paul Gantt and Ron Gantt, Safety Compliance Management, discuss human error and its effect on occupational safety. They identify the role of error traps in human error, how an organisation can identify and eliminate error traps to prevent incidents and they review case studies involving human error.
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Content ArticleResearchers have shown that people often miss the occurrence of an unexpected yet salient event if they are engaged in a different task, a phenomenon known as inattentional blindness. However, demonstrations of inattentional blindness have typically involved naive observers engaged in an unfamiliar task. What about expert searchers who have spent years honing their ability to detect small abnormalities in specific types of images? We asked 24 radiologists to perform a familiar lung-nodule detection task. A gorilla, 48 times the size of the average nodule, was inserted in the last case that was presented. Eighty-three percent of the radiologists did not see the gorilla. Eye tracking revealed that the majority of those who missed the gorilla looked directly at its location. Thus, even expert searchers, operating in their domain of expertise, are vulnerable to inattentional blindness.
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Content ArticleSteven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. In this series of posts, he outlines a number of myths, misunderstandings, and false equivalencies about Human Factors.
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Content Article
The human error trap (7 June 2017)
Patient Safety Learning posted an article in Error traps
Phillip Ragain, director of training and human performance at The RAD Group, explains why it wrong to focus on human error when an incidence occurs. A majority of incident investigations correctly identify employees who made mistakes or deviated from policies and procedures, but this distracts from other causal factors and preclude better corrective actions. In his blog, Philip discusses how leaders can avoid the human error trap. -
Content ArticleThis guidance is issued by the Health and Safety Executive, the Institution of Engineering Technology and the British Computer Society. Following the guidance is not compulsory but if you do follow the guidance you will normally be doing enough to comply with the law in Great Britain where this is regulated by the Health and Safety Executive (HSE). HSE inspectors seek to secure compliance with the law and may refer to this guidance as illustrating good practice.
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Content ArticleIn a new instalment of the Profiles in Improvement series from the US based Institute for Healthcare Improvement (IHI), Patricia McGaffigan describes her healthcare journey and why the safety movement needs a “reboot.”
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Content ArticleEffective teamwork is critical to successful outcomes in pediatric cardiac surgery. Unfortunately, lapses in professional performance and conduct by those who treat paediatric cardiac patients pose threats to quality and safety. One hallmark of a profession is self regulation. Therefore, healthcare leaders need specific means for identifying and addressing those lapses and indicators of unsafe systems or individuals. This article from Pichert et al. describes an initial “near miss” event involving a paediatric cardiac surgeon. While fictional, the case represents a composite of events involving several paediatric cardiac surgeons who practice at different medical centers throughout the US.
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Content ArticleThis blog discusses how competition can help drive improvement up to a point, but after which it may perpetuate unnecessary harm. It gives examples of where competition can become unhealthy. A more constructive approach requires collaboration focusing on patients to ensure they receive the best possible care.
