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Showing results for tags 'Human error'.
Found 272 results
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Content ArticleSir Liam Donaldson's presentation slide at the High Level Forum, Africa Patient Safety Initiative, Cape Town, South Africa 24- 25 October 2019.
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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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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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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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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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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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Content ArticleRob Hackett, Patient Safe Network, in the video below discusses the danger of Indistinct chlorhexidine which can easily be mistaken for other colourless solutions. He highlights the story of Grace Wang, who in 2010 had antiseptic solution injected into her epidural. She nearly died and was left paralysed. Indistinct chlorhexidine was mistaken for saline. The investigation recommended all skin antiseptic solutions to be coloured in a way that distinguished them. Sadly this recommendation isn't followed. Accidental chlorhexidine injections continue to occur and there are many more examples. This same error continues to play out again and again throughout the world. There’s no need for these indistinct solutions and safer distinct versions and those enclosed in swab sticks are already in use in many hospitals without problem and at no extra cost.
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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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Content ArticleThis blog from the PatientSafe Network discusses cognitive dissonance. Cognitive dissonance — the pain of accepting ego-dystonic facts — mitigates against an open, rational aggressive cycle of process improvement. Unfortunately the hierarchical structures in healthcare mean we are likely to suffer from this. Those further up, best positioned to bring about positive change, are the most likely to suffer cognitive dissonance.
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Content Article
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. -
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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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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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. -
Content ArticlePotentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies. This quality improvement study from Suliburk et al., published in JAMA Network Open, analysed the incidence of human performance deficiencies during the provision of surgical care to identify opportunities to enhance patient safety.
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PSNet: Systems Approach
Claire Cox posted an article in In health care
The Patient Safety Network (PSNet) discuss a case of a 65 year old who went in for one operation, but ended up having a completely different operation. -
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 ArticleThis paper from Helen Hughes presents a proposal to improve the safety of patients and the effectiveness of healthcare using Human Factors methods.
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Community Post
How nurses can spot and report error traps and near misses
HelenH posted a topic in Stories from the front line
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How can nurses spot error traps and near misses so that Trusts can learn, respond and take action to prevent unsafe care? What are the barriers to nurses using their insight and where is the good practice that we can share? Any ideas, anyone?- Posted
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Content ArticleHealthcare 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.
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Content ArticleAlthough many initiatives have been implemented and great strides have been achieved in improving patient safety and reducing preventable medical errors, progress towards achieving "zero" avoidable harm continues to be slow. This video presentation will address common medical errors, their recognition, potential for harm and the psychological and financial costs. The concepts of human factors, system design and the high reliability organisation will be reviewed. New approaches in reducing harm and restoring trust will be described along with the opportunity for physician leadership.
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Content ArticleTo find out how checklists and monitoring work in actual practice, Benjamin and Dismukes observed line operations during 60 flights conducted by three air carriers from two countries. They used a structured technique to observe and record checklist and monitoring performance, and situational factors that might affect performance. Because an important function of checklists and monitoring is to catch, or “trap,” operational errors, they also recorded deviations in aircraft control, navigation, communication and planning. When a deviation was observed, they tracked whether crewmembers identified and corrected it, and whether there were any consequences that might affect the outcome of the flight. They found that checklists and monitoring are not as effective as generally assumed.
