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Found 242 results
  1. Content Article
    Saturday 17 September 2022 marks the fourth annual World Patient Safety Day. This event was established by World Health Organization (WHO) as a day to call for global solidarity and concerted action to improve patient safety. It aims to bring together patients, families, carers, healthcare professionals and policymakers to show their commitment to patient safety. Avoidable harm in health and social care What is patient safety? Simply put, patient safety is concerned with avoiding unintended harm to people during their care and treatment. WHO describes it as follows: “Patient safety is a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce its impact when it does occur.”[1] Modern health and social care is incredibly complex and complicated, meaning that there are range of different ways in which unintended avoidable harm can occur. Each year, millions of patients suffer injuries or die because of this, with WHO stating that unsafe care is likely one of the top ten leading causes of death and disability worldwide.[2] In the UK, the NHS pre-Covid estimate was that there were around 11,000 avoidable deaths annually due to safety concerns, with thousands more patients seriously harmed.[3] This comes at a huge financial cost, with the Organisation for Economic Co-operation and Development (OECD) estimating that the direct cost of treating patients who have been harmed during their care in high-income countries approaches 13% of health spending.[4] Avoidable harm also has an untold physical and emotional impact on those affected, resulting in a loss of trust in the healthcare systems by patients, and frustration and a loss of morale among healthcare professionals at not being able to provide the best possible care. Need for transformation in our approach to patient safety The impact of avoidable harm and the need to make significant improvements to patient safety is well-established in health and social care. However, despite this knowledge, and the hard work of many people involved in the sector, avoidable harm continues to persist at an unacceptable rate. At Patient Safety Learning we believe that the persistence of avoidable harm is the result of our failure to address the complex systemic causes that underpin it. We argue that there needs to be a transformation in our approach to this problem. Key to this is ensuring patient safety is treated as core to the purpose of health and social care, not simply as one of several competing strategic priorities to be traded off against each other. In our report, A Blueprint for Action, underpinned by systemic analysis and evidence, we identify six foundations of safe care for patients and these practical actions to address them:[5] Shared Learning – organisations should set and deliver goals for learning, report on progress and share their insights widely for action. It is not enough to say, ‘we’ve learned from incidents of unsafe care’, we need to see action for improvement and impact. Leadership – we emphasise the importance of overarching leadership and governance for patient safety. This is not just about governance; it is about behaviours and commitment too. Professionalising patient safety – organisations need to set and deliver high standards for patient safety. These need to be used by regulators to inform their assessment of whether organisations are doing enough to prevent avoidable harm and assess whether they are safe. Patient Engagement – to ensure patients are valued and engaged in patient safety, at the point of care, if things go wrong and for redesigning health care for safety. Data and Insight – better measurement and reporting of patient safety performance, both quantitative as well as qualitative. Just Culture – all organisations should publish goals and deliver programmes to eliminate blame and fear, introduce or deepen a Just Culture, and measure and report progress. Medication safety When considering avoidable harm in health and social care, unsafe medication practices and medication-related harm are one of the leading causes of this, with WHO noting that: Medication harm accounts for 50% of the overall preventable harm in medical care.[6] $42 billion (US dollars) of global total health expenditure worldwide can be avoided if medication errors are prevented.[6] This year’s World Patient Safety Day focuses on the issue of medication safety and the need to build on the existing WHO Global Patient Safety Challenge: Medication Without Harm. The campaign emphasises the need to adopt a systems approach to this challenge, promote medication safety practices to prevent medication errors and reduce medication-related harm.[7] The Global Challenge was launched in 2017 with a goal “to gain worldwide commitment and action to reduce severe, avoidable medication-related harm by 50% in the next five years”.[8] As we reach the end of this period, Patient Safety Learning believes that it is important now that countries report publicly on their progress against this, enabling WHO evaluate both positive developments and where improvement is required. Medication safety covers a huge range of different issues and concerns and here we will highlight a few examples from Patient Safety Learning’s work and topical issues highlighted on our award-winning patient safety platform, the hub. Listening and responding to patient concerns A key barrier to improving patient safety around medication concerns the dismissal of concerns raised by patients when harmful side effects occur. A recent example of this in the UK was highlighted by the Independent Medicines and Medical Devices Safety (IMMDS) Review, which investigated a truly shocking degree of avoidable harm to patients over a period of decades relating to two medications, hormone pregnancy tests and sodium valproate, and pelvic mesh implants. The Review exposed a range of medication safety concerns, including a lack of informed consent, failures by incident reporting schemes to recognise safety concerns and a failure to support patients after unsafe care, stating: “As we have seen and heard, all too often patient reports of harm are either not listened to or are dismissed as subjective, unscientific and anecdotal.”[9] Key to highlighting these issues, and pushing for change, was the tenacious work of campaigning patients and families affected by this, as described in a recent interview on the hub with Marie Lyon, Chair of the Association for Children Damaged by Hormone Pregnancy Tests. In response to this Review there will soon be new Patient Safety Commissioner roles created in England and Scotland. While these roles can provide a new voice and hopefully influence for patients in relation to medication safety in the UK, this must also be accompanied by a shift in attitudes and approach towards patients’ involvement in care and their safety. Packaging and processes The WHO Medication Without Harm initiative recognises that one of the key challenges to the safe administration of medication often lies in complex and unclear processes which can result in mistakes that lead to patient harm. An example of this is when packaging and labelling of medications creates error traps, situations that could lead into avoidable harm in a busy, pressurised health and social care workplace, such as different medications being stored together in almost identical packaging. We have been collating different examples from healthcare professionals of look-alike medicines on our error traps gallery on the hub. We also need to look at how we can reduce the complexity around medication prescription and administration to reduce the risk of mistakes that lead to harm. Laurence Goldberg highlights examples of this such as regards to ready-to-administer injections and unit dose drug distribution in a new blog featured on the hub. Engaging with patients in the medication process Building on our previous comments around listening to patient concerns, actively involving them in their care is also a key issue in ensuring medication safety. In our recent analysis of investigation reports by the Healthcare Safety Investigation Branch (HSIB) in England we have seen numerous examples where family members of patients have played a key role in spotting and alerting healthcare professionals to safety concerns. Cases of this vary from appropriate insulin administration to safety concerns around the prescription of liquid morphine. WHO have developed a helpful tool to support patient involvement in this area, 5 Moments for Medication Safety. This helps to highlight how the risk of harm can be reduced by involving patients at different stages of the medication process. The implementation gap As with many other issues in patient safety, a key challenge in reducing medication-related harm remains overcoming the ’implementation gap‘, the difference between what we know improves patient safety and what is done in practice. In our report from earlier this year, Mind the implementation gap, we highlighted how too often we fail to translate patient safety insights and learning into practical improvements, due to a lack of systems for sharing learning, absence of oversight and unclear patient safety leadership. Returning to the IMMDS Review we can see a clear example of the implementation gap in relation to sodium valproate. Despite a clear body of evidence about the risks, birth defects or development delays associated with taking this medication during pregnancy, the safety actions identified by the review and ongoing campaigning by groups such as the Independent Fetal Anti-Convulsant Trust, pregnant women and birthing people in the UK continue to be prescribed this medication. In addition, they do not always receive the appropriate advice on the risks associated with this. There is much that still needs to be done in medication safety to improve our approach to not only sharing good practice but ensuring that this is implemented widely and consistently. Share your experience with us Do you have an experience to share around medication safety as a patient, carer or family member? Or perhaps you are a healthcare professional looking to share your frontline insights to help improve safety? Join the conversation by signing up to our patient safety platform the hub and sharing your views, or get in touch with us by emailing content@pslhub.org. Related reading You can find a wide range of medication safety related articles on issues such as medication administration, labelling, patient medication stories and medicine management on the medication section of our patient safety platform the hub. We’ve also published several articles on this subject specifically for World Patient Safety Day this year which you can find below: Patient Safety Spotlight interview with Angela Carrington, Lead Pharmacist for Medication Safety in Northern Ireland Reducing medication errors: a blog from Laurence Goldberg for World Patient Safety Day Top picks for World Patient Safety Day 2022: Medication safety in hospitals Top picks for World Patient Safety Day 2022: Patient engagement for medication safety Top picks for World Patient Safety Day 2022: Medication safety in social care References WHO, Patient safety – About us, Last Accessed 13 September 2022. WHO, 10 facts on patient safety, 26 August 2019. NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. OECD, Patient Safety, Last Accessed 20 October 2021. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. WHO, World Patient Safety Day 2022, Last Accessed 14 September 2022. WHO, Medication Without Harm, Last Accessed 14 September 2022. WHO, Medication Without Harm: WHO Global Patient Safety Challenge, 2017. The IMMDS Review, First Do No Harm, 9 July 2020
  2. Community Post
    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?
  3. News Article
    When the pain in her shoulders and weakness in her right leg started two years ago, Giovanna Ippolito thought it was just part of getting older — that's until the 46-year-old's doctor ordered an X-ray that showed a five-centimetre long, broken needle embedded in her spine. It was a medical error that took more than a decade to discover — after medical staff at the time failed to report it. Exactly when the needle was left in Ippolito's spine is unclear, but she says she's only had something injected into her back twice — during the birth of her son in 2002 and her daughter in 2004. Ippolito says she believes the needle broke off when medical staff at Mackenzie Richmond Hill Hospital in nearby Richmond Hill (called York Central Hospital at the time) administered a spinal block or an epidural during one of the births. She's now locked in a battle with the hospital for answers and accountability. But experts say, with a system that's stacked against Canadians harmed by medical errors, it's likely no one will have to take responsibility. More than 132,000 patients experienced some kind of medical harm — something both preventable and serious enough to require treatment or a longer hospital stay — in 2018-19, according to the Canadian Institute for Health Information, an independent, not-for-profit organization that collects information on the country's health systems. Read full story Source: CBC, 5 October 2020
  4. News Article
    An anaesthetist who had been drinking before an emergency caesarean that led to the death of a British woman should serve the maximum three years in jail if convicted and should be banned from working as a doctor, a French prosecutor has demanded. Helga Wauters is on trial in Pau, south-west France, for the manslaughter of Xynthia Hawke in 2014. She is accused of starving Hawke of oxygen for up to an hour after pushing a ventilation tube into the wrong passageway. Orlane Yaouang, prosecuting, described the scene in the operating theatre when Hawke turned blue as “carnage” and spoke of the “surreal situation” in which the panicked hospital staff called the emergency services. Read full story Source: The Guardian, 9 October 2020
  5. News Article
    “Human error” resulted in a man having the wrong leg amputated at a major Austrian hospital. The error occurred when a healthcare employee marked the wrong leg for amputation during pre-surgical procedures. The mistake was not noticed anytime during the surgery, or even during the immediate postoperative period. It was recognised during a routine wound dressing change, about 48 hours postoperatively. “A disastrous combination of circumstances led to the patient’s right leg being amputated instead of his left,” the hospital’s statement said. “We would also like to affirm that we will be doing everything to unravel the case, to investigate all internal processes and critically analyze them. Any necessary steps will immediately be taken.” Read full story Source: Lansing Injury Law News, 24 May 2021
  6. News Article
    The Health Information and Quality Authority (HIQA) has today published an overview report on the lessons learned from notifications of significant incident events in Ireland arising from accidental or unintended medical exposures in 2019. In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year.The most common errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nationally and international data, highlights an area for improvement.John Tuffy, Regional Manager for Ionising Radiation, said “The overall findings of our report indicate that the use of radiation in medicine in Ireland is generally quite safe for patients. The incidents which were reported to HIQA during 2019 involved relatively low radiation doses which posed limited risk to service users. However, there have been radiation incidents reported internationally which resulted in severe detrimental effects to patients so ongoing vigilance and attention is required." John Tuffy, continued “As the regulator of medical exposures, HIQA has a key role in the receipt and evaluation of notifications received. While a significant event is unwanted, reporting is a key demonstrator of a positive patient safety culture. A lack of reporting does not necessarily demonstrate an absence of risk. Reporting is important, not only to ensure an undertaking is compliant but because it improves general patient safety in a service and can minimise the probability of future preventative events occurring.” Read full story Source: HIQA, 9 September 2020
  7. News Article
    Inquest finds Susan Warby, 57, received insulin she did not need after blood test mistakes. Hospital errors contributed to her death five weeks after bowel surgery, an inquest into her death has concluded. Susan Warby, 57, who died at West Suffolk hospital in Bury St Edmunds, was incorrectly given glucose instead of saline through an arterial line that remained in place for 36 hours and resulted in inaccurate blood test readings. She was subsequently given insulin she did not need, causing bouts of extremely low blood sugar (hypoglycemia) and the development of “a brain injury of uncertain severity”, recorded Suffolk’s senior coroner, Nigel Parsley. Speaking after the inquest was adjourned in January, Susan's husband, Jon Warby, said he was “knocked sideways completely” when he received an anonymous letter two months after her death highlighting blunders in her treatment. Doctors at the hospital were reportedly asked for fingerprints as part of the hospital’s investigation into the letter, a move described by a Unison trade union official as a “witch-hunt” designed to identify the whistleblower. Following January’s adjournment, Parsley instructed an independent expert to review the care that Warby received. Warby’s medical cause of death was recorded as multi-organ failure, with contributory causes including septicaemia, pneumonia and perforated diverticular disease, affecting the bowel. Recording a narrative conclusion, Parsley wrote: “Susan Warby died as the result of the progression of a naturally occurring illness, contributed to by unnecessary insulin treatment caused by erroneous blood test results. This, in combination with her other comorbidities, reduced her physiological reserves to fight her naturally occurring illness.” Jon Warby said in a statement: “The past two years have been incredibly difficult since losing Sue, and it is still a real struggle to come to terms with her no longer being here. The inquest has been a highly distressing time for our family, having to relive how Sue died, but we are grateful that it is over and we now have some answers as to what happened." “After learning of the errors in Sue’s care, I wanted to know how these occurred and what action was being taken to prevent any similar incidents in the future. The trust has now made a number of changes which I am pleased about.” Read full story Source: The Guardian, 7 September 2020
  8. News Article
    A teenager with a severe nut allergy died in part because of human error, a coroner has ruled. Shante Turay-Thomas, 18, had a severe reaction to eating a hazelnut. The inquest heard a series of failures meant that an ambulance took more than 40 minutes to arrive at her home in Wood Green, north London. Her mother Emma Turay, who said she felt "badly let down" by the NHS, wants an "allergy tsar" to be appointed to help prevent similar deaths. The inquest heard call staff for the NHS's 111 non-emergency number failed to appreciate the teenager's worsening condition was typical of a severe allergic reaction to nuts. A telephone recording of the 111 call, made by her mother, at 23:01 BST on Friday 14 September 2018, revealed how the 18-year-old could be heard in the background struggling to breathe. "My chest hurts, my throat is closing and I feel like I'm going to pass out," she said before asking her mother to check how long the ambulance would be, then adding: "I'm going to die." The inquest heard Ms Turay-Thomas had tried to use her auto-injector adrenaline pen, however it later emerged she had only injected a 300 microgram dose, rather than the 1,000 micrograms needed to stabilise her condition. It also emerged she was unaware of the need to use two shots for the most serious allergic reactions and had not received medical training after changing her medication delivery system from the EpiPen to a new Emerade device. The inquest at St Pancras Coroner's Court was told an ambulance that was on its way to the patient had been rerouted because the call was incorrectly categorised as requiring only a category two response, rather than the more serious category one. Read full story Source: BBC News, 13 January 2020
  9. News Article
    Some Welsh NHS staff with Covid-19 have been given wrong test results and were told they did not have coronavirus, BBC Wales has learned. They are among a group of ten who have been given incorrect results - including eight from Aneurin Bevan Health Board and two from elsewhere. It is not clear how many of the ten had Covid-19 and were told they did not, or vice versa. The Gwent-based heath board said the staff were contacted "immediately". It happened when a small number of test samples from a batch of 96 were attributed to the wrong patients. Read full story Source: BBC Wales, 7 April 2020
  10. News Article
    A nurse from South Gloucestershire died after doctors missed signs of her cervical cancer amid a series of "gross" failings, a coroner has ruled. Julie O’Connor’s cancer was not picked up by North Bristol NHS Foundation Trust despite abnormalities in a smear test in 2014 and a biopsy in 2015. She went for multiple further checks for gynaecological problems in 2016 and 2017 and was referred three times to specialists. However, Ms O'Conner only received a cancer diagnosis once she decided to seek private treatment at Spire Hospital in Bristol. An inquest into her death was held in Flax Bourton, Somerset, this week. Maria Voisin, Senior Coroner for the Avon area, found the cause of Ms O’Connor’s death to be of “natural causes contributed to by neglect". She recorded three instances of "gross failures" including the inaccurate smear test as well as mistakes in two further assessments. Deputy medical director Tim Whittlestone said: “We accept the findings of the coroner and support her actions to build on our correspondence with the Royal College of Obstetricians and Gynaecologists." “...I would like to reaffirm that North Bristol has investigated these errors and more importantly that we have learnt lessons from our mistakes." Read full story Source: Nursing Times, 31 January 2020
  11. News Article
    An electronic health record (EHR) bug that transmits and medication order for 25 mg of a drug – not the prescribed 2.5 mg – could be the difference between life and death. And it’s that seemingly impossible reality that’s bringing more industry stakeholders to the table working to better understand EHR usability and its effects on patient safety. “Often times when people think about usability, they think about design and then they think about the EHR vendor,” Raj Ratwani, PhD, Director of MedStar Health Human Factors Center, said in an interview with EHRIntelligence. “In reality, it's a very complex space. The products that are being used by frontline clinicians are shaped by the vendor. But they are also shaped by how that product is implemented at that provider site, how it's customized, and how it’s configured. All of those things shape usability.” EHR usability issues are an exceptionally common issue, Ratwani reported in a recent JAMA article. About 40% EHRs reported having an issue that can potentially lead to patient harm and about 786 hospitals and 37,365 individual providers may have used EHRs with potential safety issues based on required product use reporting. Direct safety challenges typically come from EHR products that are sub-optimally designed, developed, or implemented. Usability issues stem from a very cluttered interface or a complex medication list. Seeing a cluttered list can lead to a clinician selecting the wrong medication. A major usability issue also comes from data entry. EHR users want that process to be as clean as possible. Consistency in the way information is entered is also key, Ratwani explained. Ratwani also wants to ensure that certification testing is as realistic as possible. He compared it to when a vehicle is certified to meet certain safety standards each year. This type of mechanism does not exist when it comes to EHRs because right when the product is certified, it then gets implemented, and there is no further certification of safety done at all after the initial testing. “One way to do that, at least for hospitals, is to have that process be something that the Joint Commission looks to do as part of their accreditation standards,” Ratwani said. “They could introduce some very basic accreditation standards that promote hospitals to do some very basic safety testing.” Read full story Source: EHR Intelligence, 13 January 2020
  12. News Article
    A coroner has criticised an ambulance trust after it took nearly four hours to reach a woman who had taken an overdose. Taking the unusual step of publishing a prevention of future deaths report before an inquest had concluded, coroner for Gateshead and South Tyneside Terence Carney said “the real and imminent danger of [the deceased Maureen Wharton’s] admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way”. Ms Wharton called North East Ambulance Service Trust to say she was dying of cancer and had taken prescribed drugs, including an opioid-based medication and sleeping pills. She threatened to take more and later called back, appearing drowsier. North East Ambulance Service graded the 61-year-old’s call as “category three”, which meant she should have received a response within two hours. It took three hours and 45 minutes for the ambulance service to access her flat, by which time she was already dead. Mr Carney pointed out no attempts had been made to identify family or other support for her, or to contact other agencies which could have responded. The inquest into her death is expected to conclude later this year. In a statement, NEAS said it has already made changes to safeguard patients in mental health cases, including implementing greater oversight in its control rooms, improving call transfers to crisis teams, mapping available local mental health services, introducing more staff training, and telling patients in a crisis but not at risk of physical harm about other, more appropriate, services. Read full story (paywalled) Source: HSJ, 14 January 2020
  13. News Article
    A young woman was left with a retained foreign object, after surgery in an India hospital. A checklist could have avoided her death. The response from the health officials was: “We have issued a show-cause notice to the staff seeking an explanation. We will initiate departmental action based on their replies and finding of our inquiry.” In the fields of healthcare quality and patient safety, such punitive measures of “naming and shaming” have not worked. T.S. Ravikumar, President, AIIMS Mangalagiri, Andhra Pradesh, moved back to India eight years ago with the key motive to improve accountability and safety in healthcare delivery. He believes that we have a long way to go in reducing “preventable harm” in hospitals and the health system in general. "We need to move away from fixing blame, to creating a 'blame-free culture' in healthcare, yet, with accountability. This requires both systems design for safe care and human factors engineering for slips and violations". "Providing safe care without harm is a 'team sport', and we need to work as teams and not in silos, with mutual respect and ability to speak up where we observe any deviation or non-compliance with rules, says Ravikumar. Basic quality tools and root-cause analysis for adverse events must become routine. Weekly mortality/morbidity conferences are routine in many countries, but not a routine learning tool in India. He proposes acceleration of the recent initiative of the DGHS of the Government of India to implement a National Patient Safety Framework, and set up an analytical “never events” or sentinel events reporting structure. Read full story Source: The Hindu, 12 January 2020
  14. News Article
    A review of the work of a former locum consultant radiologist in the Northern Trust has identified major discrepancies in 66 images. The trust has concluded a review of 13,030 scans and x-rays. The review was launched in June after the General Medical Council raised concerns about the locum consultant radiologist's work. The highest level of hospital investigation will be carried out into the cases of 17 patients. More than 9,000 patients were contacted as part of the review. The review identified six images at level one - a major discrepancy where errors or omissions in reporting could have had an immediate and significant clinical impact for the patients concerned. A further 60 images were level two - a major discrepancy with a probable clinical impact. "Most of the images categorised as having Level 1 and Level 2 discrepancies are CT scans but some are MRI scans, chest x-rays and other x-rays," said the trust's medical director, Seamus O'Reilly. "That detailed clinical assessment, which has resulted in 69 patients being called back, was to determine whether any clinical harm occurred as a result of the discrepancies found in the lookback review," "I can confirm that following careful consideration, the clinical assessment group has determined that 17 patients should now be part of a Level 3 Serious Adverse Incident (SAI) review." Read full story Source: BBC News, 13 October 2021
  15. News Article
    76 people were unintentionally exposed to ionising radiation in Irish hospitals in 2020, according to the Health and Information Quality Authority (HIQA). This figure represents an 11% increase on the total reported in 2019. HIQA today published an overview report on the 'increase in accidental and unintended exposure to ionising radiation events notified to HIQA in 2020. Under the European Union (Basic Safety Standards for Protection against dangers arising from Medical Exposure to Ionising Radiation) Regulations 2018 and 2019, HIQA is the competent authority for patient protection in relation to medical exposure to ionising radiation in Ireland. In its 2019 report — its first such publication — HIQA expressed hope that the areas of improvement it identified "would help reduce the likelihood of such events and drive quality improvements in safety mechanisms for medical exposures in Ireland." Despite this, eight more accidental exposure incidents were recorded in 2020 than in the previous year. Human error was identified as the main cause of accidental exposure in 58% of the incidents, however, HIQA determined that other factors likely contributed to these. Some 34% of the incidents involved the wrong patient being exposed to ionising radiation. HIQA said these exposures occurred at varying points along the medical exposure pathway. It stressed that the number of unintended exposure to ionising radiation incidents last year was small compared with the total number of procedures carried out, estimated to be in the region of three million. Read full story Source: Irish Examiner, 15 September 2021
  16. Content Article
    Having accurate patient information (for example, age, allergies, laboratory results) helps practitioners select medications, doses and routes of administration. One vital piece of information, the patient's weight, is especially important, because it is used to calculate the appropriate dose of a medication (for example, mg/kg, mcg/kg, mg/m2). A prescribed or dispensed medication dose can differ significantly from the appropriate dose because of missing or inaccurate patient weights. Patients in oncology treatment, patients with renal insufficiency, or who are elderly, paediatric or neonatal are at greater risk for adverse drug events, because they are more vulnerable to the effects of an error, and their weight may change frequently over short periods of time. Formulas such as the Cockcroft-Gault equation, which is used to calculate creatinine clearance to aid in the dosing of medications, and the Harris-Benedict formula, which is used to calculate basal metabolic rate, rely on knowledge of an accurate patient weight. Also, both height and weight are needed to use nomograms to determine body surface area and body mass index, for example, when calculating doses for chemotherapy. In the United States, most patients are weighed in pounds. But weighing and documenting patients' weights in pounds introduces the need to convert the weight into kilograms—an error-prone process—to conduct weight-based and other dosing. Another risk when measuring the patient's weight in pounds is failing to convert the weight into kilograms but recording that weight in kilograms (that is, documenting a weight of 200 lbs. as 200 kg instead of 90.9 kg), resulting in more than two-fold dosing errors. This document recommends a number of procedures to ensure accurate patient weights. Further reading Weight-based medication errors: How to tip the scale in the right direction
  17. Content Article
    Well, this sounds like I have moved from my normal citation of Greek philosophers and Classical Greek terms like ‘ergonomics’ straight through to the Avant Garde poetry of the 1950s. An error trap is an error trap. That is either profound, or Martin has got into the evidence locker again and is smoking ‘Exhibit A’. The idea I am going to advance is that an ‘error trap’ as described on the hub pages really is a simplistic trap, to trap the untrained investigator. There is, after all, a regulator of all this forensic stuff which might help here. In 2019 (when the world was simple), I said we shall look at human reasoning and biases. The Vox Populaire of you dear readers, wants to understand ‘confirmation bias’. It’s an example of an error trap in terms of poor thinking and it’s something the regulator has issued guidance upon. Indeed, there is a 90-page guide on confirmation bias in investigations when humans investigate other humans – super and proper Human Factors (HF) stuff it is. Now, as Corporal Jones (British TV sitcom for our overseas visitors) will say, don’t panic! We shall consider this stuff and the idea of what the regulator says together. Hand in hand we can get to grips with how to investigate HF stuff in a way the regulator would love. Yes, there is a regulator and no it’s not a club or institute suggesting team talks or simple two photo explanations to why people die. If you are keen to read on, I would avoid all the stuff on HF and statistical fallacy – well all the statistics stuff really - we will do this together. I taught postgraduate stats for 15 years and never lost a student, well they were found – eventually – in a statistically significant respectable time I would say! It is time to click on the image link below to see the images we are talking about and come back here. Welcome back – impressive they look and clearly the cause of the incident. Meh, no. The concept of an error trap is like a mouse trap. A mouse trap catches more than just mice – fingers of the unwary while setting the spring, and the toes and hems of the pyjamas wearing midnight snacker! These error traps catch more than what you expect. The simple idea of “look this looks like something else”, is actually an indication of sloppy thinking. Not convinced? Read on. So why is an error trap a sign that it’s the first time a person is doing forensics? Well dear reader you have correctly used the word ‘why’, and in blog 6 we discovered ‘why’ is a powerful word. We have decided the ‘how’ word is not so cool. The idea of an error trap is the ‘how’, and clever science types use the ‘why’ word. So, let’s use the word why as we look at the images on other hub pages. Look at another one and ask why. Welcome back. The first question is why, if 30 million bottles look like this, there have only been two incidents. If it was a mouse trap, then shops will be getting a call to ask for a refund – I’ve 30 million mice in the house and only two look a bit poorly. True the cat is sitting there smugly as any luddite would gazing upon any technology. Return to your favourite image and return again quickly. Welcome back. Next question is ‘why did it occur in this environment, and to this person, undertaking this job’? Ahh you might be thinking, this is the basis of human factors, the cave dweller in an environment, doing a task with a tool or bit of equipment. The error is only so in a given environment, with the caveman doing a particular task, at that moment in time. Yes, we are back to earlier blogs about what HF is, and what an accident is (see blog 5). Have another look at your second favourite image. Welcome back. The question ‘why’ starts with understanding the environment the cave dweller was using the kit in. We often get asked to review a so called ‘error trap diagnosis’ (done by other ‘professionals’ when a similar incident has occurred again) and find that there are many other causes. Let’s think about human vison and lighting. One case is the medication labels on two different bottles look very different under incandescent and fluorescent light, but in LED (especially 6500K) (especially the weird blue) they look the same. Sometimes, therefore, the environment means both labels change to look the same or sometimes different. Colour, hue and saturation means that in, for example, objects under high pressure sodium lights, all pinks and reds look the same. Slightly different for low pressure sodium lights. Now this should ring some bells from the last blog where I said a person that does team talks without an MSc or PhD might not be the person to do your HF investigation. Have a look at another image. Welcome back. Yes, you guessed it, the next why is – why did the incident occur doing that task? Well, we often find the task is poorly designed and the interaction with that bit of kit has been poorly thought through (more in later blogs about siloes). The next why is of course why that human – typically, fatigue, distraction and the alike are the guilty parties. This all should start ringing alarm bells (oh we will cover the psychology of alarms soon) in that in our first time together we decided that an accident did not have a single cause (see blog 1). No need to go away again, but a so called ‘error trap analysis’ may only be focussing on one factor – that is, the poor design of the bottles – whilst ignoring all the other factors that contributed to the accident, namely the environment, the person and the task. Look around you and see how many controls buttons, etc, all look the same. Look at the cooker in your kitchen (mind the mouse trap); look at all those buttons that look the same. On the flight deck don’t they all look the same? Are they error traps? Exactly, an error trap analysis is there for those who have not done the forensic training. The final why to ask is why did the system or equipment designer make that mistake. Well as earlier blogs have hinted, medicine is unique and we HF types have spent ages looking at oil, gas and railways, etc, but not at medicine – hence I’ve said any HF person needs to spend a lot of time understanding what each unique trust, ward, theatre, shift change is doing. What other error traps have we found not to be really an error trap you may ask – well airside operations where the levers look the same on the power unit, and this was indeed interesting but the operator was drunk. Indeed, another case the in-cab system icons did all look the same – but at that level of medication of the driver, it’s not surprising what happened. My favourite was the error trap where the operator made the mistake not because of the kit design (it was really bad), but if you do ask your brother to do the shift and they have not actually got any training/licence/ID and wear prescription glasses which are not theirs (so at security they look like the real person)… Always use the cognitive interview and use some learning from the behavioural sciences about memory. Facts remember are our friend (see blog 5) There is a nice website called ‘Bad human factors designs’. One of my students at the Royal College of Art found it many years ago and it is as good today as it has ever been. In our courses – well I’m retired now so should be past tense – we introduced the idea of the error trap along with the forensic photography section. By the end of the day the idea was that the students would settle down to dinner chatting about why an error trap analysis/conclusion originally looked like a good idea, but now they knew its limitations. Summary So, today we have used the earlier blogs to understand there is a science regulator, that seeing only an error trap analysis/conclusion is a quick way to spot the lesser quality HF investigation. In essence, looking only for the ‘error trap’ is like a film director with the camera on a tight focus, you need to widen the camera angle to see what else maybe in shot. The only bit we have not revisited is classical philosophy and as I have done so three times this week lets return to that. Voltaire well more precisely François-Marie Arouet (21 November 1694 – 30 May 1778) wrote: “To the living we owe respect, but to the dead we owe only the truth”. Which reminds us why we investigate. You may also note some clever HF maths on this page – well-hidden, but we shall return. Finally, one of my editors points out that to the naïve observer those error traps are so damn obvious you never need an HF person to tell you what went wrong. In their view it scares people away. Now, hopefully, you see why I’ve explained carefully why you need an HF forensic type as the real reason or proximate cause is hidden. This is important as healthcare now starts to move away from HF. “We have tried HF and its rubbish with no measurable outcome” and “we know about how pilots are supposed to talk to each other but it’s not like that in the emergency department – there are more than two of us”. The point is healthcare has not really tried much real HF. Next time Very finally 2021 sees me even more retired so future blogs on investigations will see guest writers. Keen young MSc/PhD wielding types (Bobbie on fatigue, Lara on ethics, Afiah on philosophy), slightly less young professorial types with dusty PhD documents talking about situational awareness (Professor Edgar), decision making (from Professor Stedmon- to kick us off), all from diverse domains, including healthcare, emergency response, transport, security, defence, etc. Read the other blogs in this series Why investigate? Part 1 Why investigate? Part 2: Where do facts come from (mummy)? Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4 When to investigate? Part 5. How or Why. Part 6 Why investigate? Part 7 – The questions and answers Why investigate? Part 9 – Making wrong decisions when we think they are the right decisions Why investigate? Part 10: Fatigue – Enter the Sandman Why investigate? Part 11: We have a situation Why investigate? Part 12: Ethics in research
  18. Content Article
    In the study, Yonash and Taylor identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, they found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania.They also found that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side, wrong site, wrong procedure, wrong patient); year; facility type; hospital bed size; hospital procedure location; procedure; body region; body part; and clinician specialty. Our findings are aligned with some of the previous research on WSS; however, the current study also addresses many gaps in the literature. We encourage readers to use the visuals in the manuscript and appendices to gain new insight into the relation among the variables associated with WSS. Ultimately, the findings reported in the current study help to convey a more complete account of the variables associated with WSS, which can be used to assist staff in making informed decisions about allocating resources to mitigate risk.
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