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Found 272 results
  1. Content Article
    An error trap is a situation that could lead into avoidable harm if not mitigated. It is a situation where the circumstances in combination with human cognitive limitations make errors more likely.[1] Error traps can be found throughout health and social care in medicines, equipment and devices, in documentation, and in many other areas we see every day while going about our daily jobs in health and social care. We want to raise awareness of these error traps on the hub but more importantly we want to hear your suggestions of what needs to be done to prevent them and examples of where action has been take and worked. View our error trap gallery and share your examples.
  2. Content Article
    Using a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia. Patel et al., following a near-miss and subsequent educational and training efforts at their institution, they conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient’s refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination. They found only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique. Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.
  3. Content Article
    Susan Warby, 57, was mistakenly given a glucose rather than a saline drip at West Suffolk Hospital after an operation for a perforated bowel in July 2018. Staff noticed a rise in blood sugar concentrations but gave her insulin to lower them rather than check the drip, which remained in place for 36 hours. In 2008 the National Patient Safety Agency made recommendations for safe arterial line management. In 2014 the Association of Anaesthetists published guidelines aimed specifically at preventing such events. Structured processes to prevent inadvertent use of a glucose-containing fluid to flush an arterial line and regular blood glucose sampling from a location other than the arterial line are only partial solutions. However, a survey of management of arterial lines undertaken in 2013 indicated that this was a common problem, that many of the NPSA recommendations were not widely implemented and that almost one third of respondents were aware of ‘wrong flush’ errors on their unit and a further third in other locations within their hospital. In this Rapid Response in the BMJ, Tim Cook says now is the time for patient representatives, clinicians, regulators and industry to work together to achieve widespread implementation of an engineered solution to prevent arterial line errors.
  4. Content Article
    As an industry, biopharmaceuticals is immature when it comes to the integration of human performance into operations. This article from BioPhorum aims to accelerate the industry’s maturity by building a greater understanding of what is desired and explaining how to get there. Human performance is believed by many companies in the biopharmaceutical industry to be a focus on human error reduction, where work outcomes will improve by adding more requirements and coercing people to try harder to be infallible. This archaic approach is not sustainable today and is not human performance. The environment that we operate within – both externally and internally – is changing and yet we are still applying decades-old mental models of what good problem solving looks like, and how this drives overall performance and results. Human performance is the way to make a shift towards systems thinking. Without making this change, organisations will continue to stagnate and actually be unable to keep up with the increasing complexity of the environments they work in, and the environments they create. This blue-sky vision of human performance takes time and patience to properly implement and must be viewed as a fundamental change to how an entire organisation executes work. Essentially, this is a transformation of the organisation’s systems and thinking over a period of several years. This article provides guidance that has worked within the biopharmaceutical industry and the unique regulatory space it operates within.
  5. 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
  6. 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
  7. Content Article
    When things go wrong, we seem to display a reliable tendency to do one thing: blame those at the ‘sharp end’. No matter how complex the system, how uncertain the situation, or how inadequate the conditions, our attention post-accident seems to turn to those proximal to the consequence, whom we judge to have failed to control the hazard in question. The notion of ‘just culture’ has developed over the past decade or so in response to this and is highly valued by front line staff. Just culture is, however, borne of the Safety-I mindset. Since the advent of ‘just culture’, the Safety-II perspective has emerged. Safety-II defines safety not as avoiding that things go wrong but as ensuring that things go right. Safety-II views the human not as a hazard, but as a resource necessary for system flexibility and resilience. In light of this, it has been proposed that the idea of just culture should be abandoned. If we take a Safety-II view, ‘just culture’ might indeed seem unnecessary. Steve Shorrock explores this further in his latest blog.
  8. Community Post
    We should all strive to keep antibiotics working for our NHS surgeons and future generations, by decreasing antibiotic use in medicine. It is mums themselves who could dramatically decrease antibiotic use, in the only medical specialty where this is possible - in obstetrics - by keeping skin intact; by being informed of the 10cm diameter that 'Aniball' and 'Epi-no Delphine Plus' birth facilitating devices, the mechanical version of Antenatal Perineal Massage, achieve by skin expansion (much like by 'earlobe skin expanders') prior to birth, for back of baby's head. This enables a normal birth for many more babies by shortening birth, with no cutting (episiotomies) or tearing, and much fewer Caesarean sections, as each Caesarean section requires antibiotics to be injected into mum, to kill any bacteria, which might have invaded a skin cell, from being implanted with that skin cell, deep into the wall of the uterus, by the surgeon's knife. There are around 750,000 births in the UK alone and three-quarters of mums are damaged during birth and at risk of developing infection; so a dramatic decrease in antibiotic use is possible. Empowering mums with knowledge; that both the skin and the coats of the pelvic floor muscles, which form the floor of the lower tummy, can be stretched painlessly, in preparation of birth, from the 26th week of pregnancy, so a gentler, kinder birth for both baby and mum becomes possible by decreasing risky obstetric interventions. Muscle can be stretched to 3 times its original length, if stretched painlessly over 6 or more occasions, and still retains its ability to recoil back, contracting to its original length. So there is no damage to mum. Baby's delicate head is not used to achieve this 'birth canal widening', because Antenatal Perineal Massage or Aniball or Epi-no Delphine Plus have already achieved this prior to the start of birth. In birth this stretching is rushed within the last 2 hours of birth, with risk of avulsion of pelvic floor muscle fibres from the pubic bone and risk of skin tearing or the need for episiotomy. The overlying skin will likewise stretch without tearing if done over 6 or more occasions. The maximal opening in the outlet or lower part of the pelvis is 10cm diameter, so 10cm diameter is the goal of the birth aiding devices and 'Antenatal Perineal Massage' or 'Birth Canal Widening' - opening doors for baby maximally. The mother reviews on 'Aniball' and 'Epi-no Delphine Plus' are impressive: Wanda Klaman, a first time mum, gives birth at nearly 42 weeks to a 4.4kg baby, with no need for episiotomy or forceps; Sophie of London, avoids episiotomy, when forceps are used to aid delivery for her baby who lays across her tummy - transverse lay, because the skin at this opening is so stretchy thanks to the birth facilitating devices. Cochrane Collaborate Report on Antenatal Massage https://pubmed.ncbi.nlm.nih.gov/23633325/ https://www.dailymail.co.uk/news/article-7450045/Fears-infections-pandemic-grow-NINETEEN-new-superbugs-discovered-UK.html https://www.mirror.co.uk/news/uk-news/mistakes-maternity-wards-setting-nhs-22702909
  9. Community Post
    See Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.
  10. 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.
  11. Content Article
    Do you ever see someone trapped into making a human error? Bad human engineering caused an error likely situation. Perhaps there was a precursor to the error – somethings that could be recognised?
  12. 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
  13. Content Article
    Since January 2019, the Health Information and Quality Authority (HIQA) has been the competent authority for regulating medical exposure to ionising radiation in Ireland and receives incident notifications of significant events arising from accidental or unintended medical exposures. As part of its role, HIQA is responsible for sharing lessons learned from significant events. HIQA has 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. This report provides an overview of the findings from these notifications and aims to share learnings from the investigations of these incidents.
  14. Content Article
    Medical errors are a serious public health problem and a leading cause of death in the United States. It is a difficult problem as it is challenging to uncover a consistent cause of errors and, even if found, to provide a consistent viable solution that minimises the chances of a recurrent event. By recognising untoward events occur, learning from them, and working toward preventing them, patient safety can be improved.  Part of the solution is to maintain a culture that works toward recognising safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organisations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers.
  15. 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
  16. 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.
  17. 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.
  18. Content Article
    In the area of patient safety, recent attention has focused on diagnostic error. The reduction of diagnostic error is an important goal because of its associated morbidity and potential preventability. A critical subset of diagnostic errors arises through cognitive errors, especially those associated with failures in perception, failed heuristics, and biases; collectively, these have been referred to as cognitive dispositions to respond (CDRs). The author of this paper, published by Academic Medicine, provides an extensive list of CDRs and a list of strategies to reduce diagnostic errors.
  19. Content Article
    Authors of this journal piece, published by The American Journal of Medicine, present a comprehensive review of the available literature and current thinking related to diagnostic error. The review covers the incidence and impact of diagnostic error, data on physician overconfidence as a contributing cause of errors, strategies to improve the accuracy of diagnostic decision making, and recommendations for future research.
  20. Content Article
    Larouzee and Le Coze describe the development of the “Swiss cheese model” and the main criticisms of this model and the motivation for these criticisms.  The article concludes that the Swiss cheese model remains a relevant model because of its systemic foundations and its sustained use in high-risk industries and encourages safety science researchers and practitioners to continue imagining alternatives combining empirical, practical and graphical approaches.
  21. Content Article
    Jerome Groopman is a doctor who discovered that he needed a doctor. When his hand was hurt, he went to six prominent surgeons and got four different opinions about what was wrong. Groopman was advised to have unnecessary surgery and got a seemingly made-up diagnosis for a nonexistent condition. Groopman, who holds a chair in medicine at Harvard Medical School, eventually found a doctor who helped. But he didn't stop wondering about why those other doctors made the wrong diagnoses. You can listed or read his interview from the link below.
  22. Content Article
    The objective of this study, published by Risk Management and Healthcare Policy, was to examine factors impacting the awareness of hospital policies and programs and their impact on the actual disclosure of medical errors.
  23. Content Article
    SLIPPS (Shared LearnIng from Practice to improve Patient Safety) is a 3 year Erasmus+ funded Patient Safety education project. The project will: draw on the real experiences of health/social care students in practice placements  utilise these experiences as the basis for a range of educational resources set up an international patient safety education network build an international open access virtual learning centre for international, multi-professional learning about patient safety Who is involved? 7 Higher Education institutions 5 Health and/or social care providers 5 European countries (UK, Finland, Spain, Italy and Norway)
  24. Content Article
    In 2008, the National Patient Safety Agency (NPSA) issued a Rapid Response Report concerning problems with infusions and sampling from arterial lines. The risk of blood sample contamination from glucose‐containing arterial line infusions was highlighted and changes in arterial line management were recommended. Despite this guidance, errors with arterial line infusions remain common. Gupta and Cook report a case of severe hypoglycaemia and neuroglycopenia caused by glucose contamination of arterial line blood samples. This case occurred despite the implementation of the practice changes recommended in the 2008 NPSA alert. They report an analysis of the factors contributing to this incident using the Yorkshire Contributory Factors Framework. They discuss the nature of the errors that occurred and list the consequent changes in practice implemented in their unit to prevent recurrence of this incident, which go well beyond those recommended by the NPSA in 2008.
  25. Content Article
    The COVID-19 pandemic has had an unprecedented impact on the delivery of healthcare services around the globe. This has resulted in important loss of life for our communities, including health professionals that have been exposed to the disease in their workplace. A human factors approach to the recent changes introduced due to the pandemic can help identify how we can minimise the impact of human error in these circumstances. Tejos et al., in Aesthetic Plastic Surgery, present a case study illustrating the application of human factors in the difficult times we are going through at present.
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