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Found 271 results
  1. Content Article
    This 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.
  2. Content Article
    Human 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.
  3. Content Article
    Adverse 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.
  4. Content Article
    This 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.
  5. Content Article
    This 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.
  6. Content Article
    Human 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.
  7. Content Article
    Since 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.
  8. Content Article
    Medicines 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.
  9. Content Article
    Handover 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.
  10. Content Article
    One 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.
  11. Content Article
    Presentation 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.
  12. Content Article
    This study aims to present two system models widely used in Human Factors and Ergonomics (HF/E) and evaluate whether the models are adoptable to England’s national patient safety team in improving the exploration and understanding of multiple incident reports of an active patient safety issue and the development of the remedial actions for a potential National Patient Safety Alert. The existing process of examining multiple incidents is based on inductive thematic analysis and forming the remedial actions is based on barrier analysis of intelligence on potential solutions. However, no formal systems models evaluated in this study have been used. AcciMap and Systems Engineering Initiative for Patient Safety (SEIPS) were selected, applied and evaluated to the analysis of two different sets of patient safety incidents: (i) incidents concerning ingestion of superabsorbent polymer granules and (ii) incidents concerning the interruption in use of High Nasal Flow Oxygen.
  13. Content Article
    Insight into medical device and system failure and the teachings of Henry Petroski, a professor of civil engineering at Duke University, who wrote about failure analysis and design theory.
  14. Content Article
    Serious 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.
  15. 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.
  16. Content Article
    The US Institute for Safe Medication Practices (ISMP) list of error-prone abbreviations, symbols, and dose designations contains abbreviations, symbols, and dose designations which have been reported through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been misinterpreted and involved in harmful or potentially harmful medication errors. These abbreviations, symbols, and dose designations should NEVER be used when communicating medical information verbally, electronically, and/or in handwritten applications. This includes internal communications; verbal, handwritten, or electronic prescriptions; handwritten and computer-generated medication labels; drug storage bin labels; medication administration records; and screens associated with pharmacy and prescriber computer order entry systems, automated dispensing cabinets, smart infusion pumps, and other medication-related technologies. 
  17. Content Article
    Confusion 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.
  18. Content Article
    This 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.
  19. Content Article
    Everybody 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.
  20. Content Article
    Sorrel King was a 32-year-old mother of four when her eighteen-month-old daughter, Josie, was horribly burned by water from a faulty water heater in the family's new Baltimore home. She was taken to Johns Hopkins--renowned as one of the best hospitals in the world--and Sorrel stayed in the hospital with Josie day-in and day-out until she had almost completely recovered. Just before her discharge, however, she was erroneously injected with methadone, and died soon after. Sorrel's account of her unlikely path from grieving parent to nationally renowned advocate is interwoven with descriptions of her and her family's slow but steady road to recovery, and ends with a deeply affecting description of a ski trip they took recently. The sun is shining, her children are healthy, and they are all profoundly happy--a condition that Sorrel has learned to appreciate all the more for Josie. The book ends with a resource guide for patients, their families, and healthcare providers; it includes information about how to best manage a hospital stay and how to handle a medical error if one does occur.
  21. Content Article
    Medication 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.
  22. Content Article
    The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is an independent body composed of 27 national organisations. In 1995, the United States Pharmacopeial Convention (USP) spearheaded the formation of the National Coordinating Council for Medication Error Reporting and Prevention: Leading national health care organizations are meeting, collaborating, and cooperating to address the interdisciplinary causes of errors and to promote the safe use of medications.
  23. 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.
  24. Content Article
    Earlier 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.
  25. Content Article
    Across 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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