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Showing results for tags 'Human error'.
Found 273 results
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Content ArticleAn examination of how humans interact with their environments and each other led a team at Spectrum Health Helen DeVos Children’s Hospital in Grand Rapids, Michigan, USA, to question one of its long-standing medication safety practices and change how they work.
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Content ArticleThis study, published in the International Journal for Quality in Health Care, examined the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences. It highlighted the complexities involved and the difficulties faced by staff in learning from incident data.
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Content ArticleThis article, published by the BMJ, discusses mandatory and voluntary medical error reporting programmes and comments that voluntary reporting by practitioners is usually more useful.
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Content ArticleDouble-checking the administration of medications has been standard practice in paediatric hospitals around the world for decades, but there is little evidence of its effectiveness in reducing errors or harm. This study in BMJ Quality & Safety measures the association between double-checking and the occurrence and potential severity of medication administration errors. The authors found that: most nurses complied with mandated double-checking, but the process was rarely independent when not carried out independently, double-checking resulted in little difference to the occurrence and severity of errors compared with single-checking where double-checking was not mandated, but was performed, errors were less likely to occur and were less serious. They raise a question about whether the current approach to double-checking is a good use of time and resources, given the limited impact it has on medication administration errors.
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News Article76 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
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Content ArticleThe Health Information and Quality Authority (HIQA) has published its annual overview report of lessons learned from receipt of statutory notifications of accidental and unintended exposures to ionising radiation in 2020. This report provides an overview of the findings from these notifications and shares learnings from the investigations of these incidents.
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Content ArticleThis Patient Safety Notice has been developed by Sandwell and West Birmingham NHS Trust following a serious incident inquest of a case involving sampling from a central line. A patient, under renal physicians, required blood cultures from their central venous line (normally used for haemodialysis). Due to unfamiliarity with the correct procedure the line was not clamped prior to use. Air therefore entered the port causing an air embolus and subsequently cardiac arrest.
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Content Article
Improving diagnosis in health care (2015)
Patient-Safety-Learning posted an article in Diagnosis
This report from The National Academies of Sciences, Engineering and Medicine highlights three key themes around the issue of diagnostic error: The importance of diagnostic error in patient safety and the need to give the subject more research attention The central role that patients play in helping to avoid diagnostic error. The idea that diagnosis is a collaborative effort involving intra- and interprofessional teamwork. It also looks at several specific issues that must be addressed to reduce diagnostic errors. -
Content ArticleThe aim of this study from Avery et al. was to determine the prevalence and nature of prescribing errors in general practice; to explore the causes, and to identify defences against error. The study involved examination of 6,048 unique prescription items for 1,777 patients. Prescribing or monitoring errors were detected for 1 in 8 patients, involving around 1 in 20 of all prescription items. The vast majority of the errors were of mild to moderate severity, with 1 in 550 items being associated with a severe error. The following factors were associated with increased risk of prescribing or monitoring errors: male gender, age less than 15 years or greater than 64 years, number of unique medication items prescribed, and being prescribed preparations in the following therapeutic areas: cardiovascular, infections, malignant disease and immunosuppression, musculoskeletal, eye, ENT and skin. Prescribing or monitoring errors were not associated with the grade of GP or whether prescriptions were issued as acute or repeat items. A wide range of underlying causes of error were identified relating to the prescriber, patient, the team, the working environment, the task, the computer system and the primary/secondary care interface. Many defences against error were also identified, including strategies employed by individual prescribers and primary care teams, and making best use of health information technology.
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Content ArticleDespite widespread recognition and known harms, serious surgical errors, known as surgical never events, endure. The California Department of Public Health (CDPH) has developed an oversight system to capture never events and a platform for process improvement that has not yet been critically appraised. This study examined surgical never events occurring in hospitals in California and summarize recommendations to prevent future events.
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Content ArticleMedicine has traditionally been one of the most cognitively demanding occupations. This paper from Bob Baron, President and Chief Consultant of The Aviation Consulting Group, discusses the limitations of human performance in the hospital environment. Human factors models are presented and used as an anchor for a randomly selected case study involving a potentially lethal medication error. The case study’s root cause analysis showed five distinct factors that were causal to the error. The human factors models, in conjunction with an overview of basic human cognition, provide the reader with the tools to understand all five findings of the case study. This paper will provide a foundation for improving medical safety by creating an awareness of the factors that influence errors in medical procedures.
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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
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Content Article
Why investigate? Part 11: We have a situation
Graham Edgar posted an article in Why investigate? Blog series
In the latest blog in the 'Why investigate' blog series, Professor Graham Edgar discusses situational awareness. -
Content ArticleThis chapter from the 'Textbook of Patient Safety and Clinical Risk Management' reviews the most common adverse events that happen in a psychiatric unit and the safety measures that are needed to decrease the risk of errors and adverse events. It also highlights the role of staff members and patients in preventing or causing the error.
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Content ArticleThis updated edition includes the latest findings on patient safety by two of the foremost authorities on medical mistakes. Two physician-professors investigate (and re-investigate) the errors endemic to modern medical care and suggest ways to prevent hospitals and doctors from inadvertently killing their patients. Emerging from these compelling stories and insights is a powerful case for change - by policymakers, hospitals, doctors, nurses, and even patients and their families. The authors underscore the depth and breadth of dangers in medical care. They also suggest basic safety procedures and hard-nosed remedies that could make erratic systems fail-safe and save countless lives.
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Content ArticleThis edition to the Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.
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Content ArticleInterruptions and multitasking are implicated as a major cause of clinical inefficiency and error. The aim of this study by Westbrook et al. was to measure the association between emergency doctors' rates of interruption and task completion times and rates.
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Content ArticleThe objective of this study from Carey et al. was to explore medical oncology outpatients' perceived experiences of errors in their cancer care. A cross-sectional survey was conducted. English-speaking medical oncology outpatients aged 18 years or older were recruited from 9 Australian cancer treatment centres. One hundred forty-eight participants perceived that an error had been made in their care, of which one third reported that the error was associated with severe harm. Of those who perceived an error had been made, less than half reported that they had received an explanation for the error and only one third reported receiving an apology or being told that steps had been taken to prevent the error from reoccurring. Patients with university or vocational level education and those who received radiotherapy or “other” treatments were significantly more likely to report an error in care. The authors concluded that here is significant scope to improve communication with patients and appropriate responses by the healthcare system after a perceived error in cancer care.
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Content ArticleHow many times have you tried to plug a USB in the wrong way round? Since both sides are usually similar on the outside, chances are that you have tried to force a USB in upside down at least once. The consequences of this mistake are usually negligible, but in healthcare, poor design can have serious repercussions. We all know how to plug in a flash drive, so why do we still slip up? Usually, it’s because we are concentrating on something more important. Imagine the same happening in a busy emergency unit where healthcare providers are carrying out life-saving procedures. They’re short on time and working under pressure. One of the paramedics is trying to resuscitate a patient who just went into cardiac arrest — he charges the defibrillator, presses “on”, but instead of shocking, the device switches off, causing the team to waste precious time. What went wrong? And how could the same issue be prevented in the future? Neil Ballinger, head of EMEA at manufacturing parts supplier EU Automation, explains the role of human factors engineering in optimising medical devices.
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Content ArticleThis book aims to teach the key principles of patient safety to a diverse audience: physicians, nurses, pharmacists, other healthcare providers, quality and safety professionals, risk managers, hospital administrators, and others. It is suitable for all levels of readers: from the senior physician trying to learn this new way of approaching his or her work, to the medical or nursing student, to the risk manager or hospital board member seeking to get more involved in institutional safety efforts. Understanding Patient Safety is divided into three main sections. In Section I, it describes the epidemiology of error, distinguishes safety from quality, discusses the key mental models that inform our modern understanding of the safety field, and summarises the policy environment for patient safety. In Section II, it reviews different error types, taking advantage of real cases to describe various kinds of mistakes and safety hazards, introduces new terminology, and discusses what we know about how errors happen and how they can be prevented. Although many prevention strategies will be touched on in Section II, more general issues regarding various strategies (from both individual institutional and broader policy perspectives) will be reviewed in Section III. After a concluding chapter, the Appendix includes a wide array of resources, from helpful Web sites to a patient safety glossary.
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Content ArticleIn Part 8 of the 'Why investigate' blog series, Martin Langham takes a look at the hub's error trap gallery and explains why when we conclude it's an error trap we are missing the bigger picture.
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Content ArticleThis study in BMC Medicine aimed to quantify the prevalence, severity and type of preventable medication harm across medical care settings. It is the largest meta-analysis to assess preventable medication harm to date. The authors found that one in 30 patients are exposed to preventable medication harm in medical care, and more than a quarter of this harm is considered severe or life-threatening. Their results support the World Health Organization’s priority of detecting and mitigating medication-related harm and highlight other potential intervention targets that should be a priority research focus.
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Content ArticleA conversation with John Wilkes (AstraZeneca), Clifford Berry (Takeda), Amy D. Wilson, Ph.D. (Biogen), and Jim Morris (NSF Health Sciences). This article is the second part of a two-part roundtable Q&A on the topic of human performance in pharmaceutical operations. Part 1 evaluated the underpinnings of human performance and provided advice to those individuals managing rapid production scale-up to support COVID-19 production demand. Here in Part 2, human performance in the context of investigation and CAPA programmes is considered.
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Content ArticleThe United States is one of only three countries in the world that does not use the metric system. Yet, every single medication prescribed today is based on it. In addition to dosages based on the metric system, some doses are also very dependent on patient weight. These include blood thinners, certain antibiotics, chemotherapy agents, and many pediatric doses. The very young, very old, and people with certain medical conditions are at the highest risk of experiencing harm because their bodies are more sensitive to the effects of an error. Calculations made with incorrect weights can have devastating, if not fatal, consequences. Further reading Patient Safety Authority Department of Health: Final recommendation to ensure accurate patient weights
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Content ArticleWrong-site surgery (WSS) is a well-known type of medical error that may cause a high degree of patient harm. In Pennsylvania, healthcare facilities are mandated to report WSS events, among other patient safety concerns, to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database.
