Search the hub
Showing results for tags 'Human error'.
Found 272 results
-
Content ArticleExpanding on his previous commentary 'What does all this safety stuff have to do with me', Dan Cohen, Patient Safety Learning's Trustee and former Chief Medical Officer at DATIX, has written this article for the hub on personal responsibility in patient safe care.
-
Content ArticleThis study, published in Patient Education and Counseling, seeks to gain understanding of breast cancer care providers’ attitudes regarding communicating with patients about diagnostic errors, to inform interventions to improve patient-provider discussions.
-
News Article
Nurse died from cervical cancer after catalogue of errors
Patient Safety Learning posted a news article in News
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 -
Content ArticleIt has been estimated that, on average, a serious mistake in medication administration occurs once in every 133 anaesthetic medications. Anaesthetic medications often have a narrow therapeutic window, raising the potential for adverse outcomes including harmful physiological disturbances, awareness, anaphylaxis and even death. Marshall and Chrimes in this editorial examine the causes of the medication‐handling problem and discuss solutions that address the human factors considerations.
-
Content ArticleIn this video, Prof Kevin Fong, Consultant Anaesthetist at UCL (University College London) is joined in a panel discussion by three other experts in Human Factors and Ergonomics (HFE): Dr Fiona Kelly, Consultant Anaesthetist and Intensivist at Royal United Hospitals Bath and lead of the Difficult Airway Society (DAS) group on HFE Prof Chris Frerk, Consultant Anaesthetist at Northampton General Hospital and CHFG (Clinical Human Factors Group)Trustee Mr Clinton John, Operating Department Practitioner and Head for Clinical Education at UCLH. They will discuss and share their top tips about HFE in the context of airway management. This forms part of a free course from Future Learn Airway Matters course to help others explore key concepts underlying safe, multidisciplinary airway management.
-
Content Article
Double checking: a second look (16 November 2015)
Patient Safety Learning posted an article in Process improvement
Double checking is a standard practice intended to improve patient safety. It is used in different areas of health care, such as medication administration, radiotherapy and blood transfusion. Some studies have found double checking to be a useful practice, which has been endorsed by agencies and individuals. The confidence in double checking exists in spite of the lack of evidence substantiating its effectiveness. In this study, Hewitt et al. asks: ‘How do front line practitioners conceptualise double checking? What are the weaknesses of double checking? What alternate views of double checking could render it a more robust process?’ The authors conclude that double checking deserves more questioning, as there are limitations to the process. Practitioners could view double checking through alternate lenses, and thus help strengthen this ubiquitous practice that is rarely challenged. -
Content ArticleIn my previous blogs I described the investigation process and where facts come from. We also pre-empted the content in this blog by saying that human factors (HF) is the scientific study of humans done by science types. It’s now time to talk ‘people’.
- Posted
- 2 comments
-
- (and 3 more)
-
Content ArticleThe need for effective teamwork and improved communication amongst caregivers is increasingly recognised in healthcare policy worldwide. As healthcare organisations navigate in highly complex contexts, they are largely dependent on thorough collaboration and sharing of information between staff at all levels. Promoting high‐quality teamwork based on effective and frequent communication is therefore essential for developing well‐functioning healthcare organisations
-
Content ArticleSamantha Batt-Rawden, Co-founder of the The Doctors' Association UK, discusses the struggles of a junior doctor and how changes in the NHS over the last 14 years has made it so much harder to do an already hard job. In this article published in the Metro, she says "that the combination of spiralling workloads and a decimation of morale and camaraderie has been toxic for the profession." Last year, 55% of UK doctors met the criteria for burnout and ‘emotional exhaustion’, with one in five resorting to the use of drugs or alcohol as a ‘coping strategy’. It’s hardly surprising that we are haemorrhaging doctors out of the profession, and it’s only getting worse. So, how do we fix this? Sally suggests that we need to treat staff like human beings if we are going to have any hope of stemming the exodus of clinicians. It’s as simple as restoring some on-call rooms so we can get our heads down, and stop crashing our cars on the way home. Or it’s as basic as ensuring that junior doctors have leave for our own weddings. Honestly, at this stage, just letting us have access to now-outlawed NHS coffee overnight would be a significant morale boost.
-
News Article
Ways to identify EHR usability issues and reduce patient harm
Patient Safety Learning posted a news article in News
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 -
Content ArticleThe reference event in this HSIB investigation is the case of a 58-year-old woman who deteriorated and died within 24-hours of presenting at hospital, two weeks after having surgery. The national investigation reviewed relevant research and safety literature relating to recognition and response to deteriorating patients, engaged with national subject matter advisors and consulted with professional bodies.
-
News Article
Coroner raps trust for not realising woman was in ‘imminent danger’
Patient Safety Learning posted a news article in News
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 -
News Article
India: When a ‘never event’ hits a patient
Patient Safety Learning posted a news article in News
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 -
News Article
Shante Turay-Thomas: Human error factor in allergy death
Patient Safety Learning posted a news article in News
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 -
Content ArticleIn 1991, the Institute of Medicine released a landmark report revealing that as many as 98,000 patients a year were dying due to avoidable medical error. But even more recent research indicates that estimate was, if anything, a drastic understatement of the patient-safety crisis in the US healthcare system. In Malpractice, neurosurgeon and attorney Dr. Larry Schlachter demonstrates how most patients enter the system without any idea of the risks they face due to a medical culture that avoids transparency, perpetuates an atmosphere of blind deference to doctors, and protects dangerous doctors from any accountability. Drawing on twenty-three years of experience, Dr. Schlachter recounts unbelievable stories that illustrate the host of risks patients face whenever they seek diagnostic evaluation or go under the knife. This book brings readers inside the healthcare citadel, exposing the flawed culture that can fuel egos and outlining the steps every patent should take to protect himself or herself in “a bitter pill for an industry that for many years has avoided the hardest conversations about patient safety.”—Dr. Michael Dogali, MDCM, FACS, president of Pacific Neurosurgery
-
Content Article
Blog: Working together to create a more just culture in the NHS
Claire Cox posted an article in Second victim
This blog written by Frankie Hill, a Matron undertaking a secondment in clinical leadership, and Sarah De-Biase, Improvement Associate with the Improvement Academy, discusses the impact on staff when something goes wrong in healthcare. A just and learning culture is the balance of fairness, justice, learning and taking responsibility for actions. -
Content ArticleThreat and Error Management (TEM) is an overarching safety concept regarding aviation operations and human performance. TEM is not a revolutionary concept, but one that has evolved gradually, as a consequence of the constant drive to improve the margins of safety in aviation operations through the practical integration of Human Factors knowledge. TEM was developed as a product of collective aviation industry experience. Such experience fostered the recognition that past studies and, most importantly, operational consideration of human performance in aviation had largely overlooked the most important factor influencing human performance in dynamic work environments: the interaction between people and the operational context (i.e., organisational, regulatory and environmental factors) within which people discharged their operational duties. This article gives the background to TEM, components of the TEM Framework, related articles and further reading.
- Posted
- 1 comment
-
- (and 2 more)
-
Content ArticleFatigue is a complex phenomenon that has effects on physical characteristics, cognition, behaviours, and physical and mental health. Paramedicine crosses the boundaries of many high-risk industries, namely medicine, transport and aviation. The effects of fatigue on paramedics need to be explored and considered in order to begin to identify appropriate interventions and management strategies. This article, published in the Irish Journal of Paramedicine, demonstrates that fatigue is associated with increased errors and adverse events, increased chronic disease and injury rates, depression and anxiety, and impaired driving ability. It has suggested that paramedic services and paramedics need to work collaboratively to identify and action appropriate measures to reduce the effects of fatigue on the wellbeing of the workforce and mitigate its effects on clinical performance and safety.
-
Content ArticleEveryday across the NHS, patients, their supporters and the professionals caring for them deal with the aftermath of healthcare harm and, on rare occasions, wrongdoing. Every healthcare system in the world confronts exactly the same problem, but none deal well with the aftermath of harm. In this article published in the Journal of Patient Safety and Risk Management, Anderson-Wallace and Shale introduce a set of standards that aims to make the consequences less devastating for everyone.
-
Content Article
Errors in medicine (June 2009)
PatientSafetyLearning Team posted an article in Research papers
The authors of this paper, published in Clinica Chimica Acta, argue that in the current health care organisational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety: We need to move from looking at errors as individual failures to realising they are caused by system failures We must move from a punitive environment to a just culture We move from secrecy to transparency Care changes from being provider (doctors) centred to being patient-centred We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, inter-professional teamwork Accountability is universal and reciprocal, not top-down. -
Content ArticleInformation overload can be defined as a difficulty a person can have in comprehending issue and making judgments that are caused by the presence of too much information. Information overload occurs when the amount of input to a system surpasses its processing capability. Decision-makers have a limited cognitive processing ability. Consequently, when information overload happens, it is possible that a decline in decision quality will take place. Decision-makers, such as medical consultants, have fairly limited cognitive processing capacity. Consequently, when information overload occurs, it is likely that a reduction in decision quality will occur. The aim of this study, originally published by the Journal of Biosciences and Medicines, is to assess the impact of information overload on medical consultants’ life, its causes, and potential ways to deal with it.
-
Content Article
Baby’s death from heart defect was avoidable (August 2019)
Claire Cox posted an article in PHSO investigations
The Parliamentary and Health Service Ombudsman (PHSO) were set up by Parliament to provide an independent complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. They share findings from casework to help Parliament scrutinise public service providers. They also share their findings more widely to help drive improvements in public services and complaint handling. Miss K complained to the PSHO about the care and treatment that her son, Baby K, received at the Trust in November 2015. She said that the Trust failed to act following various checks on Baby K, and it failed to escalate his care in line with the seriousness of his condition and he died as a result. Miss K also complained about the Trust’s handling of her complaint. -
Content Article
Re-leveling: how stories ground us (December 2019)
Claire Cox posted an article in Blogs and vlogs
This short blog by an anonymous writer discusses making mistakes. What does it feel like to make a mistake and more so, whats it like admitting it? -
Content ArticlePatient-centred, high-quality health are relies on the well-being, health and safety of healthcare clinicians. However, alarmingly high rates of clinician burnout in the US are detrimental to the quality of care being provided, harmful to individuals in the workforce and costly. It is important to take a systemic approach to address burnout that focuses on the structure, organisation, and culture of healthcare. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being explores the extent, consequences, and contributing factors of clinician burnout and provides a framework for a systems approach to clinician burnout and professional well-being, a research agenda to advance clinician well-being, and recommendations for the field.
-
Content ArticleThe use of artificial intelligence (AI) in patient care currently is one of the most exciting and controversial topics. It is set to become one of the fastest growing industries, and politicians are putting their weight behind this, as much to improve patient care as to exploit new economic opportunities. In 2018, the then UK Prime Minister pledged that the UK would become one of the global leaders in the development of AI in healthcare and its widespread use in the NHS. The Secretary for Health and Social Care, Matt Hancock, is a self-professed patient registered with Babylon Health’s GP at Hand system, which offers an AI-driven symptom checker coupled with online general practice (GP) consultations replacing visits at regular GP clinics.
