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Showing results for tags 'Human error'.
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Content ArticleAuthors 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.
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- Diagnostic error
- Diagnosis
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Content ArticleThis paper from Helen Hughes presents a proposal to improve the safety of patients and the effectiveness of healthcare using Human Factors methods.
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- Human error
- Staff factors
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Content ArticleThe 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.
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- Policies
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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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- Risk management
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Content ArticleSLIPPS (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)
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Content ArticleThe 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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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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- Virus
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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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- User centred design
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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.- Posted
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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.
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- Cancer
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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.
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- Patient harmed
- Human error
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Content ArticleThe human element can give us kindness and compassion; it can also give us what we don't want — mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
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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.
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- Staff support
- Staff factors
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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’.
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- Investigation
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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.
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- Doctor
- Anaesthetist
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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
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- Communication
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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.
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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.- Posted
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- Second victim
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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.- Posted
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- Baby
- Patient death
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Content ArticleHospital Watchdog is a nonprofit patient advocacy organisation in the US that champions safe hospital care for patients. They are a diverse group that includes nurses, physicians, pharmacists, healthcare experts, attorneys and members of the public. Some of them have experienced or witnessed medical errors that led to an extremely serious or tragic outcome. They are committed to improving unsafe conditions in hospitals. In February 2019, Hospital Watchdog conducted an in-depth interview with Ms. Dena Royal, a former paramedic, and respiratory therapist. Dena’s mother, Martha Wright, bled to death following a colonoscopy and a series of tragic nursing mistakes at Cass Regional Medical Center in Harrisonville Missouri.
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- Human error
- Organisational learning
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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?- Posted
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- Human error
- Perception / understanding
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Content ArticleWhen Julie Bailey took her mother, Bella, into Mid Staffs Hospital in September 2007 she had no idea that her life was about to change forever. Over the next eight weeks she would witness such shocking neglect and abuse of elderly, vulnerable patients that the memories would haunt her for the rest of her life. And over the next five years she would uncover a culture of deceit and denial going right to the top of the NHS. From Ward to Whitehall is the story of Julie s fight for the truth to be uncovered about the deadly failings at Mid Staffs Hospital and her struggle to ensure that the tragedy would never be repeated.
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- Human error
- Latent error
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Content ArticleRecently, there have been a number of advances in technology, including in mobile devices, globalization of companies, display technologies and healthcare, all of which require significant input and evaluation from human factors specialists. Accordingly, this textbook has been completely updated, with some chapters folded into other chapters and new chapters added where needed. The text continues to fill the need for a textbook that bridges the gap between the conceptual and empirical foundations of the field.
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- Human error
- Latent error
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Content ArticleWhen faced with a ‘human error’ problem, you may be tempted to ask 'Why didn’t these people watch out better?' Or, 'How can I get my people more engaged in safety?' You might think you can solve your safety problems by telling your people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure and demanding compliance. These are all expressions of 'The Bad Apple Theory' where you believe your system is basically safe if it were not for those few unreliable people in it.
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Content ArticleIncreased concern for patient safety has put the issue at the top of the agenda of practitioners, hospitals, and even governments. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. Yet the discourse is often oversimplified and underdeveloped. Written from a scientific, human factors perspective, Patient Safety: A Human Factors Approach delineates a method that can enlighten and clarify this discourse as well as put us on a better path to correcting the issues.
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- Human error
- Organisation / service factors
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