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Showing results for tags 'Human error'.
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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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- Tests / investigations
- Workspace design
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Content ArticlePublished by wbur, an American news station, this account from a doctor tells the story of his father's admission to hospital. Dr. Ashish Jha lists a catalogue of errors that took place over those few days, notes how common these mistakes are and argues we should be less tolerant of poor patient safety in healthcare.
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- Patient safety incident
- Near miss
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Content ArticlePatient-centred, high-quality health are relies on the well-being, health and safety of healthcare clinicians. However, alarmingly high rates of clinician burnout in the US are detrimental to the quality of care being provided, harmful to individuals in the workforce and costly. It is important to take a systemic approach to address burnout that focuses on the structure, organisation, and culture of healthcare. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being explores the extent, consequences, and contributing factors of clinician burnout and provides a framework for a systems approach to clinician burnout and professional well-being, a research agenda to advance clinician well-being, and recommendations for the field.
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- Fatigue / exhaustion
- Human error
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Content ArticleSafety in aviation has often been compared with safety in healthcare. This article, published in JRSM Open, presents a comprehensive review of similarities and differences between aviation and healthcare and the application to healthcare of lessons learned in aviation.
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- Link analysis
- Assessment
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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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- Leadership
- Team leadership
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Content ArticleThe use of artificial intelligence (AI) in patient care currently is one of the most exciting and controversial topics. It is set to become one of the fastest growing industries, and politicians are putting their weight behind this, as much to improve patient care as to exploit new economic opportunities. In 2018, the then UK Prime Minister pledged that the UK would become one of the global leaders in the development of AI in healthcare and its widespread use in the NHS. The Secretary for Health and Social Care, Matt Hancock, is a self-professed patient registered with Babylon Health’s GP at Hand system, which offers an AI-driven symptom checker coupled with online general practice (GP) consultations replacing visits at regular GP clinics.
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- AI
- Human error
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Content ArticleTo Err Is Human breaks the silence that has surrounded medical errors and their consequence – but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda – with state and local implications – for reducing medical errors and improving patient safety through the design of a safer health system.
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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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- Human error
- Patient accident
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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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- Investigation
- Patient death
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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.- Posted
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- Human error
- Doctor
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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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- Human error
- Ergonomics
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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.- Posted
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- Human error
- Safety culture
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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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- Human error
- Ergonomics
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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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- System safety
- Human error
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Content ArticleGetting to grips with human factors – strategic actions for safer care is a learning resource from the Clinical Human Factors Group (CHFG) that recognises the fundamental impact boards have on safety within their organisation. The aim of the resource is to encourage boards to invest time and resource in human factors, by raising awareness of human factors and demonstrating how human factors impact on quality, safety and productivity in healthcare. It is intended to be thought provoking, encouraging board members to think about themselves and their organisation whilst also providing practical actions that boards and individual members can and should be making in this area.
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- Safety management
- Human error
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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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- System safety
- Work / environment factors
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Content ArticleSteven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. The term 'human factor' is rarely defined, but people often refer to reducing it. In this blog, Steven asks what are we actually reducing?
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- Human error
- Heuristics
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Content ArticlePete Smith is nothing without the energy and commitment of the amazing people who surround him. Increasing the technical skill of a healthcare clinician makes for incremental change. Improve the culture within which they work, think and communicate and suddenly quantum change is possible. Two perioperative nurses from a regional hospital in Victoria, Australia, innovated a simple, elegant solution to the problem of noise and distraction in the operating room. Pete Smith was one of them.
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- Operating theatre / recovery
- Surgeon
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) latest report highlights that mislabelling of blood samples could pose a deadly risk to patients. The reference event in the report is a case where patient details became mixed up on blood samples sent from a maternity unit. In the case of mislabelling on blood transfusion samples, the impact could be devastating. There’s the potential for serious injuries and even death.
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- Near miss
- Blood / blood products
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Human error: models and management
Claire Cox posted an article in Improving patient safety
In this BMJ article, James Reason discusses how the human error problem can be viewed in two ways: the person approach and the system approach. Each has its model of error causation and each model gives rise to quite different philosophies of error management. Understanding these differences has important practical implications for coping with the ever present risk of mishaps in clinical practice.- Posted
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- Cognitive tasks
- Distractions/ interruptions
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Content ArticleMore than 30 years have passed since the near-fatal medication error but Michael Villeneuve recalls the moment with absolute clarity. Now the chief executive officer at the Canadian Nurses Association, Villeneuve frequently draws upon that experience in his day-to-day work to promote better care, better health and better nursing across Canada. Watch this short video, produced by the Canadian Patient Safety Institute (CPSI) to hear more about his experience.
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- Near miss
- Human error
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Content ArticleIn many safety-critical environments, including healthcare, operators need to remember to perform a deferred task, which requires prospective memory. Laboratory experiments suggest that extended prospective memory retention intervals, and interruptions in those retention intervals, could impair prospective memory performance.
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- Human error
- Memory
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Content Article
Patient Stories: Paul's Story (10 March 2013)
Claire Cox posted an article in Patient stories
In 2007, when Paul Richards was diagnosed with non-Hodgkin lymphoma, his family were stunned by the news. This powerful film from Patient Stories is based on the testimony of Lisa, Paul’s wife, who gives a moving account of the events that led to Paul’s death and explores the effects on their family. -
Content Article
Letter from America: Lift off!
lzipperer posted an article in Letter from America
I’d like to introduce my ‘Letter from America’, a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery.- Posted
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- Diagnosis
- Checklists
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