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Showing results for tags 'Human error'.
Found 272 results
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Content ArticlePotentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies. This quality improvement study from Suliburk et al., published in JAMA Network Open, analysed the incidence of human performance deficiencies during the provision of surgical care to identify opportunities to enhance patient safety.
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Content Article
PSNet: Systems Approach
Claire Cox posted an article in In health care
The Patient Safety Network (PSNet) discuss a case of a 65 year old who went in for one operation, but ended up having a completely different operation. -
Content ArticleHealthcare Safety Investigation Branch (HSIB) report on the inadvertent administration of an oral liquid medicine into a vein. This report indicated the importance of using human factors in the investigation process. The investigation reviewed the effectiveness of the current processes for the storage of medicines, equipment design, and the prescribing, preparation, checking and administration of medication. It also considered the contextual, environmental and human factors that influenced the inadvertent administration of an oral solution into a vein. The effectiveness of current processes for implementation of local safety standards for invasive procedures was also considered. A human factors expert was involved in the investigation and a dedicated report was written based on the evidence reviewed, a reconstruction of the event and a simulation of what should have happened.
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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 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 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.
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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
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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.
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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.
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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.
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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 ArticleSir Liam Donaldson's presentation slide at the High Level Forum, Africa Patient Safety Initiative, Cape Town, South Africa 24- 25 October 2019.
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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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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 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.
