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Showing results for tags 'Human error'.
Found 272 results
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News Article
Doctor admits killing patient in botched routine procedure
Patient Safety Learning posted a news article in News
A mother was killed at her hospital appointment by a doctor who botched a routine procedure, a court has heard. Dr Isyaka Mamman, 85, was responsible for a series of critical incidents before the fatal appointment, Manchester Crown Court heard. Mamman, who admitted gross negligence manslaughter, had already been sacked by medical watchdogs for lying about his age but was re-employed by the Royal Oldham Hospital. He is due to be sentenced on Tuesday. Mother-of-three Shahida Parveen, 48, had gone to hospital with her husband for investigations into possible myeloproliferative disorder on 3 September 2018 and a bone marrow biopsy had been advised, Andrew Thomas QC, prosecuting, told the hearing. Normally, bone marrow samples are taken from the hip bone but Mamman, of Cumberland Drive, Royton, Oldham, failed to obtain a sample at the first attempt, he said. Instead, he attempted a rare and "highly dangerous" procedure of getting a sample from Ms Parveen's sternum - despite objections from the patient and her husband, the court heard. Mamman, using the wrong biopsy needle, missed the bone and pierced her pericardium, the sac containing the heart, causing massive internal bleeding. Ms Parveen lost consciousness as soon as the needle was inserted. She died later that day. Read full story Source: BBC News, 4 July 2022 -
Content Article
Impact of adverse events on surgeons (April 2022)
Patient Safety Learning posted an article in Surgery
Surgeons are affected negatively when things go wrong. They may experience guilt, anxiety and reduced confidence following adverse events, which may lead to formal investigation and sanction. Medical errors have been linked with burnout, depression, suicidal ideation and reduced quality of life. This research from Turner et al. explores the impact of adverse events on UK surgeons’ health and wellbeing. Surgeons completed an online survey that involved recalling an error-based or complication-based event and answering questions regarding health, wellbeing and support seeking. -
Content ArticleThis webinar by the Institute for Safe Medication Practices is aimed at healthcare providers and patient safety specialists. The conversation covers lessons learned in the aftermath of a fatal medication error and looks at common, yet often unresolved, system vulnerabilities. It also examines key strategies and priorities needed to advance an organisation's safety journey.
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Content ArticleHuman error plays a vital role in diagnostic errors in the emergency department. A thorough analysis of these human errors, using information-rich reports of serious adverse events (SAEs), could help to better study and understand the causes of these errors and formulate more specific recommendations. Baartmans et al. studied 23 SAE reports of diagnostic events in emergency departments of Dutch general hospitals and identified human errors. They found that the combination of different instruments and information-rich SAE reports allowed for a deeper understanding of the mechanisms underlying diagnostic error. Results indicated that errors occurred most often during the assessment and the testing phase of the diagnostic process. Most often, the errors could be classified as mistakes and violations, both intended actions. These types of errors are in need of different recommendations for improvement, as mistakes are often knowledge based, whereas violations often happen because of work and time pressure. These analyses provided valuable insights for more overarching recommendations to improve diagnostic safety and would be recommended to use in future research and analysis of (serious) adverse events.
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Content ArticleAdverse events in surgery are a relevant cause of costs, disability, or death, and their incidence is a key quality indicator that plays an important role in the future of health care. In neurosurgery, little is known about the frequency of adverse events and the contribution of human error. The aim of this study from Meyer et al. was to determine the incidence, nature and severity of adverse events in neurosurgery, and to investigate the contribution of human error. They found that adverse events occur frequently in neurosurgery. These data can serve as benchmarks when discussing quality-based accreditation and reimbursement in upcoming health care reforms. The high frequency of human performance deficiencies contributing to adverse events shows that there is potential to further eliminate avoidable patient harm.
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Content ArticleThis Chartered Institute of Ergonomics and Human Factors (CIEHF) webinar explores near misses in three different sectors and how controls can, or cannot, be developed to prevent future events.
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Content ArticleThis editorial in BMJ Quality & Safety looks at the risks to patient safety posed by negative interpersonal interactions between healthcare professionals. The authors review a recent study on the subject by Linda Guo et al that revealed how and when these negative behaviours from staff may have an impact on patient outcomes and clinical performance. They highlight the huge scale of the impact of unacceptable behaviours, arguing that it is even greater than evidenced in Guo et al's research. They also highlight that there are other, largely unexplored impacts on healthcare workers, patients and their families when they are exposed to unacceptable interactions.
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Content ArticleHuman error is as old as humankind itself and widely recognised as a significant cause of mistakes. Much of the research in this area has originated from high-risk organisations (HROs), including commercial aviation, where even simple mistakes can be catastrophic. A failure to understand and recognise how Human Factors (HF), especially those that affect performance and team working, can contribute or lead to serious medical error is still widespread across healthcare. Sadly, this commonly occurs in the operating theatre, one of the most dangerous places in hospital. While attitudes and acceptance of pre-surgery briefings has improved using the World Health Service (WHO) Surgical Checklist, this does not address other 'personal' factors that can lead to error, including stress, fatigue, emotional status, hunger and situational awareness. Following initial work around HF perception amongst operating theatre teams, Peter Brennan's (student at the University of Portsmouth) research has lead to significant delivery changes to the high stakes Membership of the Royal College of Surgeons (MRCS) examination, taken by up tp 6,500 junior doctors per year. After recognising boredom and fatigue in examiners, further published studies found an improvement in examiner morale with no significant changes in exam reliability or overall candidate outcome. These changes have improved patient safety at a National level. Other high stakes National Events have been evaluated where repetitive assessment occurs during long days, providing reassurance to organisers and the General Medical Council. 28 HF-related publications have been included in this work, including several reviews of important personal factors that affect performance and how these can be optimised at work.
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Content ArticleSince the Covid-19 pandemic, staff shortages have worsened in health systems around the world, with an increasing number of healthcare workers leaving the workforce coinciding with increased patient demand. In this blog, Jens Hooiveld, International Marketing Manager at the Patient Safety Company, examines the patient safety issues caused by staffing shortages. He highlights tools that can help nurses manage patient safety in this pressured climate by decreasing the burden of admin associated with reporting adverse incidents.
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Content ArticleMedicines reconciliation is the process of accurately listing a person’s medicines. This could be when they're admitted into a service or when their treatment changes.
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Content ArticleHandover in healthcare settings can be a time when the risk of error and harm is increased. This blog summarises the results of global survey that asked the opinions of healthcare workers on the safety of handover. It highlights ten key points raised by the results: Handover causes frequent errors and patient safety incidents Handover errors can cause serious harm to patients Most people think they are better than average at handover The longer you’ve been around, the scarier handover appears Different types of handovers have a similar safety profile The safety of handover is a problem all over the world Most practitioners use manual or informal systems to support handover EPR systems are not up to the job of supporting handover Staff need more training, and we need more time Healthcare leaders want better electronic systems The results of the survey have been published in Preprints.
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Content ArticleOne box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable – does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture.
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News ArticleRaDonda Vaught was sentenced to three years of supervised probation on the 13 May for a fatal medication error she made in 2017 while working as a nurse at the Vanderbilt University Medical Center in the USA. In remarks made during the sentencing hearing, Ms. Vaught expressed concerns over what her case means for clinicians and patient safety reporting. "This sentencing is bound to have an effect on how [nurses] proceed both in reporting medical errors, medication errors, raising concerns if they see something they feel needs to be brought to someone's attention," she said. "I worry this is going to have a deep impact on patient safety." Numerous medical organisations expressed similar concerns in statements circulated after Ms. Vaught's sentencing. "To achieve our goal of zero patient harm and death from preventable medical errors, we need to foster a culture where leadership of hospitals and healthcare organizations support healthcare workers and encourage them to share near misses," the Patient Safety Movement Foundation said in a statement. "Healthcare workers are human and healthcare systems need to ensure there are appropriate processes in place to provide their staff with a safe and reliable working environment so they can provide their patients with the best care. Only by identifying potential problems and learning from them can change occur." Read full story Source: Becker's Hospital Review, 16 May 2022
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Content ArticleAlthough serious medication errors are uncommon, their effects can be devastating for patients and their loved ones. The authors of this study in the journal Patient Safety searched the Pennsylvania Patient Safety Reporting System (PA-PSRS) for reports of serious medication errors in the emergency department from 1 January 2011 to 31 December 2020. They identified trends in the data, looking at patient sex, patient age, event harm score, event day of the week and event time of day. The authors found that: error reports more often specified that the patient was female. events were significantly more likely to happen over the weekend. most errors occurred at the prescribing stage. the most common error type was a wrong dose. They conclude that a number of patient safety strategies could reduce the risk of medication errors in the emergency department, including: stocking epinephrine autoinjectors. using clinical decision support at the ordering/prescribing stage of the process. adding an emergency medicine pharmacist to interdisciplinary emergency medicine teams.
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Content ArticleEZDrugID is a campaign to improve the distinctiveness of medication packaging set up by a group of healthcare workers. Inadequate standards around medication packaging mean that medications with very different actions are sometimes packaged in a very similar way causing "look-alike drugs”. This can lead to errors and serious harm to patients if the wrong drug is mistakenly used. The EZDrugID website contains information about their campaigns to maximise distinctiveness of different medications as well as a "lookalikes" gallery. See also: the hub's error traps gallery The medication safety area of the hub
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Content ArticlePositive defensive medicine describes an approach to healthcare that involves excessive testing, over-diagnosing and overtreatment. Negative defensive medicine, on the contrary, describes an approach where doctors avoid, refer or transfer high risk patients. This article in Patient Safety in Surgery examines how both defensive medicine approaches can contribute to medical errors.
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Content ArticleDr Robert D. Glatter, medical advisor for Medscape Emergency Medicine, Dr Megan Ranney, professor of emergency medicine and the academic dean at Brown University School of Public Health and Dr Jane Barnsteiner, emeritus professor at the University of Pennsylvania School of Nursing, discuss the tragic case involving RaDonda Vaught, who was an ICU nurse who was recently convicted in Tennessee of criminally negligent homicide and gross neglect following a medical error due to administration of the wrong medication that led to a patient's death.
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Content ArticlePresentation on the of theme of prevention of medication error from Philip A Routledge and James Coulson (All Wales Therapeutics and Toxicology Centre). Presentation available as slides a written transcript.
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News ArticleOn 25 March2022, a Tennessee jury convicted RaDonda Vaught, a nurse at Vanderbilt University Medical Center, of criminally negligent homicide and impaired adult abuse in a 2017 medication administration error that tragically resulted in a patient death. The Washington State Nurses Association have issued a joint statement adamantly opposed to criminalization of patient care errors. "Focusing on blame and punishment solves nothing. It can only discourage reporting and drive errors underground. It not only undermines patient safety; it fosters an environment of fear and lack of respect for health care workers." "The Vaught case has drawn intense national attention and concern. We join with health care workers and patient safety experts around the country and the world in rejecting the criminalization of medical errors. Further, we are committed to redoubling our efforts to achieve health care environments that are safe for patients and health care workers alike. This includes the ongoing, critical fight to achieve safe staffing standards in Washington state." Read full statement Source: Washington State Nurses Association, 8 April 2022
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Content ArticleThis webpage provides an overview of how human factors affect outcomes in surgical emergencies. It includes: An introduction to human factors Video exploring the case of Elaine Bromiley Explanation of human error and the Swiss Cheese Model Table of factors that reduce human error 'What if?' video showing how simple changes could have resulted in a different outcome in Elaine Bromiley's case Practical tips for managing the paediatric airway in a critically ill child
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News Article
Why nurses are raging and quitting after the RaDonda Vaught verdict
Patient Safety Learning posted a news article in News
Emma Moore felt cornered. At a community health clinic in Portland, Oregon, USA, the 29-year-old nurse practitioner said she felt overwhelmed and undertrained. Coronavirus patients flooded the clinic for two years, and Moore struggled to keep up. Then the stakes became clear. On 25 March, about 2,400 miles away in a Tennessee courtroom, former nurse RaDonda Vaught was convicted of two felonies and facing eight years in prison for a fatal medication mistake. Like many nurses, Moore wondered if that could be her. She'd made medication errors before, although none so grievous. But what about the next one? In the pressure cooker of pandemic-era health care, another mistake felt inevitable. Four days after Vaught's verdict, Moore quit. She said Vaught's verdict contributed to her decision. "It's not worth the possibility or the likelihood that this will happen," Moore said, "if I'm in a situation where I'm set up to fail." In the wake of Vaught's trial ― an extremely rare case of a health care worker being criminally prosecuted for a medical error ― nurses and nursing organizations have condemned the verdict through tens of thousands of social media posts, shares, comments, and videos. They warn that the fallout will ripple through their profession, demoralizing and depleting the ranks of nurses already stretched thin by the pandemic. Ultimately, they say, it will worsen health care for all. Read full story Source: Kaiser Health News, 5 April 2022 -
Content Article“Don't go to the hospital alone” has been the advice that safety experts have promoted for many years as a way that patients can help protect themselves. Family members provide an important safety net for patients in the hospital, and across the entire continuum of care—another slice of the Swiss cheese in our defenses against errors. As safety professionals, we hate to have to rely on that safety net, knowing that not all patients and families are able to provide it. Yet, given what we know about the frequency of medical errors, we still recommend it because families provide an additional cross-check of our care. But the COVID-19 pandemic has stripped away the layer of protection provided by families. At the start of the pandemic, visitation was heavily curtailed or stopped entirely due to the risks of spreading the virus. These decisions were not made lightly—concerns about protecting patients and the workforce drove them. Risks of visitation have included risks of infection to visitors and staff, particularly when not enough personal protective equipment (PPE) was available, and added strain on nurses to manage the presence of visitors and visitors’ compliance with PPE protocols. These infection concerns have not borne out, especially after adequate PPE supplies became available.1.,2. Those decisions at the start of the pandemic were necessary, given the uncertainties and the PPE shortages. However, now is the time to learn from that experience and reassess the risks and benefits of limited visitation. Further reading It’s time to rename the ‘visitor’: reflections from a relative Visiting restrictions and the impact on patients and their families: a relative's perspective Q&A: Dr. Tejal Gandhi on refocusing COVID visitation policies through a safety lens
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News Article
Guilty verdict for nurse RaDonda Vaught’s dosing mistake could cost lives
Patient Safety Learning posted a news article in News
Patient safety and nursing groups around the country are lamenting the guilty verdict in the trial of a former nurse in Tennessee, USA. The moment nurse RaDonda Vaught realised she had given a patient the wrong medication, she rushed to the doctors working to revive 75-year-old Charlene Murphey and told them what she had done. Within hours, she made a full report of her mistake to the Vanderbilt University Medical Center. Murphey died the next day, on 27 December 2017. On Friday, a jury found Vaught guilty of criminally negligent homicide and gross neglect. That verdict — and the fact that Vaught was charged at all — worries patient safety and nursing groups that have worked for years to move hospital culture away from cover-ups, blame and punishment, and toward the honest reporting of mistakes. The move to a “Just Culture" seeks to improve safety by analyzing human errors and making systemic changes to prevent their recurrence. And that can't happen if providers think they could go to prison, they say. “The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent,” the American Nurses Association said. “Health care delivery is highly complex. It is inevitable that mistakes will happen. ... It is completely unrealistic to think otherwise.” Read full story Source: The Independent, 31 March 2022 -
Content ArticleThe Patient Safety Movement are looking for patients, family members, health workers and administrators to reach out if they have an experience related to harm or death due to a medication error in the operating room. While the specific numbers may be debated, that medication errors, while rare in the operating, could have catastrophic consequences. The Patient Safety Movement are interested in hearing your perspective concerning this issue. Please email events@patientsafetymovement.org if you have a story that you’d like to share. If you are worried about anonymity please submit your story at the link below.
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News ArticleRaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide on Friday after a three-day trial in Nashville, Tenn., that gripped nurses across the country. Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney's office. Vaught is scheduled to be sentenced 13, and her sentences are likely to run concurrently, said the district attorney's spokesperson, Steve Hayslip. Vaught was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide. Vaught's trial has been closely watched by nurses and medical professionals across the U.S., many of whom worry it could set a precedent of criminalising medical mistakes. Medical errors are generally handled by professional licensing boards or civil courts, and criminal prosecutions like Vaught's case are exceedingly rare. Read full story Source: OPB, 26 March 2022 See also: As a nurse in the US faces prison for a deadly error, her colleagues worry: Could I be next?
