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Showing results for tags 'Human error'.
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Content ArticleThis article in Time reviews the documentary film 'To Err is Human', which explores the tragic outcomes of medical errors and the medical culture that allows them to persist. The film follows the Sheridans, a family from Boise, Idaho on their journey to understand how two major medical errors befell their family: one that contributed to a case of cerebral palsy, and another that involved a delayed cancer diagnosis and ended in death.
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Content Article
Blog - Is human error a crime? (2 November 2022)
Patient-Safety-Learning posted an article in Legal matters
Martin Anderson, author of the Human Factors 101 blog, looks at the case of US nurse RaDonda Vaught, who was found guilty of criminally negligent homicide and abuse of an impaired adult following a medication error that led to a patient death in 2017. He provides a timeline of the events that occurred in the run up to the criminal trial and highlights concerns that the case will set a precedent in bringing criminal charges against nurses when there is no intent to harm a patient. He then looks at the system factors that may have contributed to the medication error, asking a number of questions about the circumstances under which Vaught made the error. The blog goes on to outline the serious impact the case could have on healthcare professionals' willingness to report errors, take on complex cases and use innovative treatments—it may even put people off taking on a career in the healthcare sector in the first place. -
News Article
Drug shortages linked with medication errors, study results suggest
Patient Safety Learning posted a news article in News
A French study of adverse drug reactions has a highlighted a link between drug shortages and medication error. Data from the French Pharmacovigilance Database show that medication errors were identified in 11% of the 462 cases mentioning a drug shortage. The researchers found that medication errors usually occurred at the administration step and involved a human factor. “A drug shortage may lead to a replacement of the unavailable product by an alternative,” the researchers wrote. “However, this alternative may have different packaging, labelling, dosage and sometimes a different route of administration that may increase the risk of a medication error.” Read full story (paywalled) Source: The Pharmaceutical Journal, 11 October 2022 -
Content ArticlePreventable harm, from the systems of care intended to improve health, continues to occur at an unacceptable rate in the United States. Healthcare systems have an opportunity to learn and improve from each episode of preventable harm. Accordingly, every preventable patient death or injury must energise our efforts to prevent future patient harm. The Anesthesia Patient Safety Foundation (APSF) believes that criminal prosecution of healthcare providers will make the work of preventing harm more difficult since it continues to shift the focus away from system improvements. They have released a position and policy statement outlining the rationale for opposing criminal prosecution and, equally important, recommends that all healthcare systems and organisations aggressively act, now, to improve their culture, processes, and training to reduce errors of all kinds and, specifically in light of recent events, medication errors. Some specific actions are recommended as examples of what can be done. Individual healthcare professionals should be mindful of their role in preventing errors and reporting errors that occur as well as taking action to encourage and enable their organization to improve the flaws in the systems in which they work that lead to harm to patients.
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Content ArticleLearning from mistakes generally is considered the upside to failure. But in healthcare, where staff members regularly face stressors and systemic issues that impede a strong culture of safety, creating that standard can be difficult. To understand why medical mistakes and care complications occur repeatedly Becker's spoke with Patricia McGaffigan, vice president of safety programmes for the Institute for Healthcare Improvement. Ms. McGaffigan outlined three factors that contribute to repeat medical errors, care complications or lost progress on quality improvement initiatives: A "whack-a-mole" approach to safety. Lack of focus on systemwide changes. Unhealthy or unsafe work environments.
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Content ArticleSafety in aviation and maritime domains has greatly improved over the years, but there is no room for complacency. This is especially the case as we approach systems with ever more automation and use of remote control in both industries. It is also more complicated because ‘human error’ is often seen as the root cause, when usually it is the system that leads people into mistakes, and seafarers and flight crew alike so often save the day. Accidents, incidents and near misses all offer us valuable lessons from which to improve safety, to do better next time. Yet in the aftermath of adverse events, the wish to blame someone, which makes sense of something that was never intended to happen, might make us lose sight of the real causes of accidents, leading to more tragedy and loss. The key to learning is using the right tool with which to understand what happened and why. This means going beyond the surface ‘facts’ and suppositions, seeing beneath the ‘usual suspects’ of factors that yield little in terms of how to prevent the next one. The SHIELD (Safety Human Incident & Error Learning Database) taxonomy has been developed by reviewing a number of existing taxonomies - in this case, a set of related terms for describing human performance and error - to derive a means of objectively classifying events in a way that helps us develop safety countermeasures afterwards. Whilst it can analyse single events it is particularly insightful when looking - and learning - across related events
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Content ArticleMr B was 71 years' old and was undergoing treatment for cancer of the oesophagus. During surgery, a nasogastric tube that had been inserted became dislodged and was put back into place by medical staff, despite guidelines against this. The family realised that something had gone wrong in the operation and Mr B became very seriously ill, dying five months later. When the family asked the hospital for an investigation, they revealed that a hole had been made in Mr B’s stomach when the nasogastric tube was replaced. There was no assurance given that steps would be taken to prevent similar errors in the future, and no apology from the hospital. The family sought legal advice and came to an out of court settlement with the hospital.
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on errors and designing system-based solutions to improve patient safety. Key learning objectives: Understand what Human Factors are Learning from incidents Designing system-based solutions Preventing human error Blame and psychological safety Just culture Register
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Content ArticleIn this analysis, published by the Human Factors and Ergonomics Society, the authors look at the impact of double checking medication to reduce errors and improve patient safety.
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Content ArticleM was a young boy who had severe asthma, resulting in regular trips to A&E. His condition was eventually well controlled with a Seretide inhaler. When M's family moved house and changed their GP, they requested a new prescription of Seretide, but when they got to the pharmacy were given the wrong type of inhaler used to treat a different form of asthma. The GP had unwittingly chosen the wrong medication from a drop-down menu. M and his family were unaware that he was taking the wrong medication, and after a few days, M became breathless and his family decided to take him to hospital. Sadly, he died on the journey to A&E. At the inquest, the Coroner found that there two main issues that contributed to M’s death: the unintentional prescription of Serevent the failure to arrange and organise follow up contributed to M’s death.
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Content ArticleThis dashboard presents the results of a patient safety survey conducted by the European Alliance for Access to Safe Medicines (EAASM) and European Collaborative Action on Medication Errors and Traceability (ECAMET). The dashboard shows variations in different hospital-reported measures of patient safety across thirteen European countries. The questions in the survey focus on accreditation, training, electronic health records and recording, tracking and publishing of medication error data.
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Content ArticleSerious incident (SI) investigations aim to identify factors that caused or could have caused serious patient harm. This study from Mary Dixon-Woods and colleagues aimed to use the Human Factors Analysis Classification System (HFACS) to characterise the contributory factors identified in SI investigation reports.
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News Article
Nurse struck off for failing to dispense morphine
Patient Safety Learning posted a news article in News
A nurse in Somerset has been struck off after she failed to give morphine to a patient before they underwent surgery. Amanda-Jane Price had been suspended from front-line duties since the incident in March 2019. The Nursing and Midwifery Council ruled that Miss Price had been "dishonest" with her colleagues and her ability to practice medicine safely was "impaired". Miss Price had been a nurse at Musgrove Park Hospital in Taunton since 2018. On 31 March 2019, Miss Price did not administer morphine to an individual in her care, falsely recording in her notes that morphine had been given. An investigation by the hospital's emergency medicine consultant found that the morphine dose of 6mg had been noted on the patient's chart, but that the drug had not actually been administered. Miss Price subsequently admitted to falsifying the prescription chart, and to "being consciously aware of her decision". As a result of Miss Price's actions, the patient underwent an invasive procedure without analgesia, and subsequently complained of being in pain. The panel concluded that Miss Price was guilty of misconduct and would initially be suspended. "This was deliberate dishonesty which concealed her failure in clinical issues and caused actual patient harm to a vulnerable victim," the panel concluded. Read full story Source: BBC News, 20 September 2022 -
Content Article
In this blog, Patient Safety Learning marks World Patient Safety Day 2022. It sets out the scale of avoidable harm in health and social care, the need for a transformation in our approach to patient safety and considers the theme of this year’s World Patient Safety Day, medication safety. -
Content Article
This year's World Patient Safety Day, due to take place on Saturday 17 September 2022, will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. In this blog for the hub, Laurence Goldberg, an independent pharmaceutical consultant, looks at how we can reduce drug administration errors by the provision of medicines in a ‘ready-to-administer’ format where no manipulation is required before administration to the patient. -
Content ArticleConfusion between drug names that look and sound alike continues to occur and causes harm in all care settings, despite persistent prevention and mitigation efforts by industry, regulators, health systems, clinicians, patients and families. This editorial in BMJ Quality & Safety examines the results of a study that assessed the effect of mixed case (often referred to as ‘tall man’) text enhancement on critical care nurses’ ability to correctly identify a specific syringe from an array of similarly labelled syringes. The authors suggest further developments in this field of research and argue that a variety of different interventions will be needed to reduce medication errors caused by drug name confusion.
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Content ArticleEverybody makes mistakes at work but what if you're a doctor and you ruin a patient's life - or even end it? Doctor-turned-writer Jed Mercurio recalls a catalogue of errors from his years as a medical student.
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Content ArticleMedication errors are any Patient Safety Incidents (PSI) where there has been an error in the process of prescribing, preparing, dispensing, and administering, monitoring or providing advice on medicines. Medication errors can occur at many steps in patient care, from ordering the medication to the time when the patient is administered the drug. From April 1 2015 to 31 March 2020 NHS Resolution received 1,420 claims relating to errors in the medication process. Of those claims, 487 claims settled with damages paid, costing the NHS £35 million (excluding legal costs). NHS Resolution initial data for medication errors indicates that anticoagulants, opioids, antimicrobials, antidepressants, and anticonvulsants are the most common medications to be implicated in incidents.
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Content ArticleThis study in JAMA Network Open aimed to investigate how often patients who read open ambulatory visit notes perceive mistakes, and what types of mistakes they report. The results of the study showed that: 1 in 5 patients who read a note reported finding a mistake 40% perceived the mistake as serious the most common mistakes reported were mistakes in diagnoses, medical history, medications, physical examination, test results, notes on the wrong patient and sidedness. The authors suggest that patients may perceive important errors in their visit notes, and inviting them to report mistakes may be associated with improved record accuracy and patient engagement in safety.
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Content ArticleEarlier this year in March, a nurse from Vanderbilt University, RaDonda Vaught, was found guilty of criminally negligent homicide and gross neglect of a patient. In 2017, Vaught gave 75-year-old Charlene Murphey the incorrect medication. Murphey died as a result. Charlene Murphey’s tragic death highlights the failures of healthcare organisations and their leadership to be trustworthy as well as a fractured and weakened accountability system for patient safety in the United States.
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News Article
Family welcomes new guidance to prevent breathing tube deaths
Patient Safety Learning posted a news article in News
A grieving family has welcomed new guidance to try to prevent a common surgical procedure from going wrong and causing deaths. Oesophageal intubation occurs when a breathing tube is placed into the oesophagus, the tube leading to the stomach, instead of the trachea, the tube leading to the windpipe. It can lead to brain damage or death if not spotted promptly. Glenda Logsdail died at Milton Keynes University Hospital in 2020 after a breathing tube was accidentally inserted into her oesophagus. The 60-year-old radiographer was being prepared for an appendicitis operation when the error occurred. Her family welcomed the guidance, saying in a statement: “We miss her terribly but we know that she’d be happy that something good will come from her tragic death and that nobody else will go through what we’ve had to go through as a family." Oesophageal intubation can occur for a number of reasons including technical difficulties, clinician inexperience, movement of the tube or “distorted anatomy”. The mistake is relatively common but usually detected quickly with no resulting harm. The new guidance, published in the journal Anaesthesia, recommends that exhaled carbon dioxide monitoring and pulse oximetry – which measures oxygen levels in the blood – should be available and used for all procedures that require a breathing tube. Experts from the UK and Australia also recommended the use of a video-laryngoscope – an intubation device fitted with a video camera to improve the view – when a breathing tube is being inserted. Read full story Source: The Independent,18 August 2022 -
Content ArticleAcross multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.
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Content ArticleNHS Resolution received 172 claims relating to anti-infective medications between 1 April 2015 until 31 March 2020. Anti-infective medications include antibiotics, antivirals and antifungals. The analysis in this leaflet focuses on closed claims that have been settled with damages paid and concern an element of the prescribing process: prescribing, transcribing, dispensing, administering and monitoring. Claims concerning a failure to recognise that an anti-infective was indicated have not been included within the analysis.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to the use of a flush fluid and blood sampling from an arterial line in people who are critically ill in hospital. As its ‘reference case’, the investigation uses the experience of Keith, a 66 year old man who during a stay in a clinical care unit had blood samples taken from an arterial line which were contaminated with the flush fluid containing glucose. As a result he received incorrect treatment which led to his blood glucose levels being reduced to below the recommended limit.
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Content ArticleEach year, 7,000 to 9,000 people die as a result of a medication errors in the US, and the total cost of looking after patients with medication-associated errors exceeds $40 billion. Alongside this financial cost, adverse events caused by medication errors also cause patients significant psychological and physical pain and suffering. The article aims to: identify the most common medication errors. review some of the critical points at which medication errors are most likely to occur. outline strategies to prevent medication errors occurring. summarise multidisciplinary team strategies for decreasing medication errors.
