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Showing results for tags 'Human error'.
Found 272 results
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Content ArticleDr Donna Prosser joins Dr Danielle Ofri to discuss the history of medical errors and how they have greatly impacted hospitals during this time of COVID-19.
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Content ArticleMaryanne Mariyaselvam, Clinical Research Fellow at Queen Elizabeth Hospital, presenting at this year's Improving Patient Safety & Care 2020 conference: Safer culture, safer systems, safer patients.
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Content ArticleUser-testing and subsequent modification of clinical guidelines increases health professionals’ information retrieval and comprehension, but no study has investigated whether this results in safer care. Jones et al. compared the frequency of medication errors when administering an intravenous medicine using the current National Health Service Injectable Medicines Guide (IMG) versus an IMG version revised with user-testing. Participants were on-duty nurses/midwives who regularly prepared intravenous medicines. Using a training manikin in their clinical area, participants administered a voriconazole infusion, a high-risk medicine requiring several steps to prepare. They were randomised to use current IMG guidelines or IMG guidelines revised with user-testing.
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Content Article
Patient Safety Authority: Wrong-site surgery
Patient Safety Learning posted an article in Surgery
Analysis of wrong-site surgery events in Pennsylvania suggests opportunities for prevention. Many steps of preparing the patient for an operation and performing an operation can lead down the path of wrong-site surgery. Preventing wrong-site surgery may require attention at every step of the process. The Patient Safety Authority has provided resources, guidelines and education tools. -
Content ArticleHuman Factors (Ergonomics) is the study of human activity (inside and outside of work). Its purpose as a scientific discipline is to enhance wellbeing and performance of individuals and organisations. A number of different definitions of Human Factors exist. The key principles are the interactions between you and your environment both inside and outside of work and the tools and technologies you use. This webpage from NHS Education Scotland (NES) provides links to a number of useful Human Factors resources used in healthcare. Topics include: Training Culture Leadership Systems Thinking Communication.
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Content ArticleNewly qualified nurses often fear making or identifying a clinical error so it is vital to know how best to prevent errors and manage them when they have occurred. This Nursing Times article looks at the most common clinical errors that are made, explains where to find the policies and procedures that should be followed, and highlights tips and tools that can be used to help rectify the issue or prevent it from happening in the first place.
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Content ArticleThis paper, published in BMJ Quality & Safety, provides national estimates of the number and clinical and economic burden of medication errors in the National Health Service (NHS) in England. Authors conclude that ubiquitous medicines use in health care leads unsurprisingly to high numbers of medication errors, although most are not clinically important. There is significant uncertainty around estimates due to the assumption that avoidable adverse drug events correspond to medication errors, data quality and lack of data around longer-term impacts of errors. Data linkage between errors and patient outcomes is essential to progress understanding in this area.
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Content ArticleThe Human Connection is a comprehensive set of clear and resonant stories that illustrate the impact of ergonomics and human factors, produced by the Chartered Institute of Ergonomics and Human Factors (CIEHF). The 60-page document is intended to be of value to a wide range of audiences, including government, policy makers, industry, third sector groups, educators, research funders, regulatory bodies and collaborators. The case studies, available here as the complete set or individually, have been written to increase understanding of the complexity, range and value of the discipline of ergonomics and human factors.
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Content ArticleThe Chartered Institute of Ergonomics and Human Factors (CIEHF) presents advice from the experts. Consultant Anaesthetist Michael Moneypenny discusses how Human Factors experts can help NHS staff cope with fatigue, while Professor Kristy Sanderson discusses the risks and tactics. Both the President and the Chief Executive of the CIEHF offer their expert opinion in this short podcast aimed at frontline workers.
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Content Article
Diagnosis: COVID Blindness (April 2020)
PatientSafetyLearning Team posted an article in Blogs
In this article, published by Diagnosis, Linden Brown reflects on his time working with COVID-19 patients. He recalls an incident where a case of sepsis was nearly missed due to what he calls 'COVID-blindness'. "In the panic of quarantine and isolation precautions, we put on cognitive blinders to our bread and butter: sepsis. Had this patient come into the hospital 2 weeks prior, he would likely have been placed on antibiotics immediately." -
Content ArticleAs the death toll from COVID-19 rapidly increases, the need to make a timely and accurate diagnosis has never been greater. Even before the pandemic, diagnostic errors (i.e., missed, delayed, and incorrect diagnoses) had been one of the leading contributors to harm in health care. The COVID-19 pandemic is likely to increase the risk of such errors. Based on emerging literature and collaborative discussions across the globe, Gandhi and Singh propose a new typology of diagnostic errors of concern in the COVID-19 era. These errors span the entire continuum of care and have both systems-based and cognitive origins. While some errors arise from previously described clinical reasoning fallacies, others are unique to the pandemic. We provide a user-friendly nomenclature while describing eight types of diagnostic errors and highlight mitigation strategies to reduce potential preventable harm caused by those errors.
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Content ArticleThe human factors ‘Dirty Dozen’ is a concept developed by Gordon DuPont. He described elements that can act as precursors to accidents or incidents, or influence people to make mistakes. This article by the Clinical Excellence Commission introduces the 'dirty dozen' and offers practical tips on how to reduced error int he workplace.
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Content ArticleUsing human factors science increases the likelihood of obtaining well-designed and easy to use products to deliver safe patient care. Poor designs, by contrast, can cause unintended harm to patients. This guide, developed by the Clinical Human Factors Group, is to help staff working in procurement or with medical devices and equipment, to use human factors to specify and select the best and safest products to use in healthcare. This is important because conformity with regulations and standards does not always guarantee safe outcomes when products are used in practice. This guide is particularly relevant to medical devices but can be used for other healthcare products.
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News Article
Coronavirus: NHS staff with Covid-19 given wrong test results
Patient Safety Learning posted a news article in News
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 -
Content ArticleThis podcast, published by Coda, covers a wide array of topics, from PPE to simulation. Martin Bromiley (Human Factors expert), talks about the ways human factors affect teams and safety and share communications tactics to help alleviate potential issues.
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Content ArticleThe Medicines and Healthcare products Regulatory Agency issued this guidance following recent cases, including cases with fatal outcomes, in which patients have received the wrong medicine due to confusion between similarly named or sounding brand or generic names.
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Content ArticleThe existence of confusing drug names is one of the most common causes of medication error and is of concern worldwide. With tens of thousands of drugs currently on the market, the potential for error due to confusing drug names is significant. This includes nonproprietary names and proprietary (brand or trade-marked) names. Many drug names look or sound like other drug names. Contributing to this confusion are illegible handwriting, incomplete knowledge of drug names, newly available products, similar packaging or labelling, similar clinical use, similar strengths, dosage forms, frequency of administration, and the failure of manufacturers and regulatory authorities to recognise the potential for error and to conduct rigorous risk assessments for nonproprietary and brand names, prior to approving new product names This article from the WHO Collaborating Centre for Patient Safety Solutions looks at the issues and suggests actions.
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Content ArticlePresentation slides for topic 5 of the WHO Multi-professional Patient Safety Curriculum Guide. The learning objective from this topic is to understand the nature of error and how healthcare providers can learn from errors to improve patient safety.
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Content Article
A conversation with pathologist, Professor Peter Johnston
Claire Cox posted an article in Processes
As part of Patient Safety Awareness Week 2020, the Royal College of Pathologists speak to Professor Peter Johnston about preventing patient harm in laboratory settings. -
Content ArticleMore than 30 years have passed since the near-fatal medication error but Michael Villeneuve, CEO Canadian Nursing Association, recalls the moment with absolute clarity.
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Content ArticleThis book examines the concept of medical narcissism and how error disclosure to patients and families is often compromised by the health professional’s need to preserve his or her self-esteem at the cost of honouring the patient’s right to the unvarnished truth about what has happened. This ground-breaking book explores common psychological reactions of healthcare professionals to the commission of a serious harm-causing error and the variety of obstacles that can compromise ethically sound, truthful disclosure.
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Content ArticleThis report is the Healthcare Safety Investigation Branch (HSIB) first complete investigation which relates to the implantation of the wrong prostheses (artificial body parts) during joint replacement surgery — a surgical never event. A never event is a serious incident that is entirely preventable.
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Content ArticleThe primary purpose of this document from the Society of Petroleum Engineers (SPE) is to allow HSE professionals who provide answers to the pre-qualification questionnaires to quickly establish if their companies apply human factors / human performance as per the industry guidance. Secondly, this guidance may be used by anyone who wishes to quickly get an insight into the industry guidance, without reading dozens of reports. To access the report you will need to fill in a form from the SPE website.
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Content ArticleThis document from the Patient Safety Authority outlines final recommendations to acute care facilities in the USA regarding patient weights. The Patient Safety Authority is responsible for submitting recommendations to the Department of Health (Department) in the US for changes in health care practices and procedures which may be instituted for the purpose of reducing the number and severity of serious events and incidents.
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Content ArticleThe struggle to perform well is universal, but nowhere is this drive to do better more important than in medicine. In his book, Atul Gawande explores how doctors strive to close the gap between best intentions and best performance in the face of obstacles that sometimes seem insurmountable. His vivid stories take us to battlefield surgical tents in Iraq, to a polio outbreak in India and to malpractice courtrooms around the country. He discusses the ethical dilemmas of doctors' participation in lethal injections, examines the influence of money on modern medicine and recounts the astoundingly contentious history of hand-washing. Finally, he gives a brutally honest insight into life as a practising surgeon. Unflinching but compassionate, Gawande's investigation into medical professionals and their progression from good to great provides a detailed blueprint for success that can be used by everyone.
