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Showing results for tags 'Near miss'.
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Content ArticlePsychological safety, a shared belief that interpersonal risk taking is safe, is an important determinant of incident reporting. However, how psychological safety affects near-miss reporting is unclear, as near misses contain contrasting cues that highlight both resilience (“we avoided failure”) and vulnerability (“we nearly failed”). Near misses offer learning opportunities for addressing underlying causes of potential incidents, and it is crucial to understand what facilitates near-miss reporting. This study by Jung et al. found near misses are not processed and reported equally. The effect of psychological safety on reporting near misses becomes stronger with their increasing proximity to a negative outcome. Educating healthcare workers to properly identify near misses and fostering psychological safety may increase near-miss reporting and improve patient safety.
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Content ArticleThe focus on error detection and its management has not produced the expected gains in patient safety, primarily because these methods are not well suited to a complex adaptive system such as healthcare. Behaviours that produce errors are variations on the same processes that produce success, so focusing on successful practices may be a more effective tactic. One approach to focusing on success is positive deviance. While positive deviance can be used to describe the behaviour of an exemplary individual, the term can also be extended to describe the behaviours of successful teams and organisations. Originating in international public health projects, positive deviance has recently been embraced to improve quality and safety of healthcare delivered in organisations. The premise is that solutions to common problems mostly exist within clinical communities rather than externally with policy makers or managers, and that identifiable members of a community have tacit knowledge and wisdom that can be generalised. Lawton et al. explain more in this BMJ article.
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Content ArticleThis document defines the investigation framework in the event of a patient safety Serous Incident (SI) related to NHS Wales Informatics Service (NWIS) delivered or supported services, which affects one or more health body in Wales.
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Content ArticleMaternal near miss is a major global health issue; approximately 7 million women worldwide experience it each year. Maternal near miss can have several different health consequences and can affect the women’s quality of life, yet little is known about the size and magnitude of this association. The aim of this study from von Rosen et al. was to assess the evidence of the association between women who have experienced maternal near miss and quality of life and women who had an uncomplicated pregnancy and delivery.
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Community Post
Champion clinicians in building AI for surgical safety
Yesh posted a topic in Artificial Intelligence
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Subject: Looking for Clinical Champions (Patient Safety Managers, Risk Managers, Nurses, Frontline clinical staff) to join AI startup Hello colleagues, I am Yesh. I am the founder and CEO of Scalpel. <www.scalpel.ai> We are on a mission to make surgery safer and more efficient with ZERO preventable incidents across the globe. We are building an AI (artificially intelligent) assistant for surgical teams so that they can perform safer and more efficient operations. (I know AI is vaguely used everywhere these days, to be very specific, we use a sensor fusion approach and deploy Computer Vision, Natural Language Processing and Data Analytics in the operating room to address preventable patient safety incidents in surgery.) We have been working for multiple NHS trusts including Leeds, Birmingham and Glasgow for the past two years. For a successful adoption of our technology into the wider healthcare ecosystem, we are looking for champion clinicians who have a deeper understanding of the pitfalls in the current surgical safety protocols, innovation process in healthcare and would like to make a true difference with cutting edge technology. You will be part of a collaborative and growing team of engineers and data scientists based in our central London office. This role is an opportunity for you to collaborate in making a difference in billions of lives that lack access to safe surgery. Please contact me for further details. Thank you Yesh yesh@scalpel.ai
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Content ArticleIn this review, Jane Carthey and colleagues discuss human factors research in cardiac surgery and other medical domains. The authors describe a systems approach to understanding human factors in cardiac surgery and summarise the lessons that have been learned about critical incident and near-miss reporting in other high technology industries that are pertinent to this field.
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Content ArticleThe use of healthcare complaints to improve quality and safety has been limited by a lack of reliable analysis tools and uncertainty about the insights that can be obtained. The Healthcare Complaints Analysis Tool, developed by Alex Gillespie and Tom W. Reader was used to analyse a benchmark national data set, conceptualise a systematic analysis, and identify the added value of complaint data.
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Content ArticleUsing a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia. Patel et al., following a near-miss and subsequent educational and training efforts at their institution, they conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient’s refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination. They found only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique. Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.
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Content ArticleNear miss events are much more common than events where harm actually reaches a patient, as much as 7-100 times more frequent. However, reporting systems for such events are much less common. At Faulkner Hospital, over 75% of the safety event reports the hospital captures in RL6 are near misses.
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Content ArticleHealthcare Quarterly is a Canadian publication and this issue, supported by the Canadian Patient Safety Institute (CPSI), focuses on patient safety.
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Content Article
Annual SHOT report 2019
Patient Safety Learning posted an article in Other
SHOT (Serious Hazards of Transfusion) is the UK's independent professionally led haemovigilance scheme. This year’s Annual SHOT Report looks back at trends and data for the last calendar year, but also highlights several very important messages for us in the present extraordinary times. The data in the report come from across the UK and include material from all areas of healthcare where transfusion is practised. -
Content ArticleThis second comprehensive edition of these Principles is to help public authorities, industry and communities worldwide anticipate accidents involving hazardous substances resulting from technological and natural disasters, as well as sabotage. It addresses the following issues: preventing the occurrence of chemical accidents and near-misses; preparing for accidents through emergency planning, public communication, etc.; responding to accidents and minimising their adverse effects; and following-up to accidents, regarding clean-up, reporting and investigation.
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Content Article
Misuse of hydrogen peroxide in a theatre environment
Kathy Nabbie posted an article in Good practice
A tutor once told me that research means 'to search again'. I am always searching or, as someone told me recently, 'sleuthing' for knowledge to improve myself and then share with my colleagues. I would like to share with you my knowledge of hydrogen peroxide. -
Community Post
The Patient Safety Incident Response Framework
Jon Holt posted a topic in Investigations, risk management and legal issues
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Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?- Posted
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Content Article
Walk on by...
Anonymous posted an article in Florence in the Machine
This anonymous blog is about a patient with learning disabilities, his treatment and outcome while coming in for a 'routine' procedure. This blog highlights the need for adequate training for all staff around caring for patients with learning disabilities to prevent harm and protracted length of stay.- Posted
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Content ArticlePeter Duffy, consultant surgeon writes of his 35 years of experience on the front-line of the NHS. Charting his career pathway from auxiliary nurse and unskilled operating theatre orderly, he takes us through his progress to senior consultant surgeon and head of department. In 2015, and after blowing the whistle on a series of near misses, he reluctantly reported an avoidable death, cover-up and ongoing surgical risk-taking to the Care Quality Commission. Within months he was out of work and unemployed. Via avoidable deaths and errors, cover-ups, misuse of public funds, bullying, abuse and victimisation the author charts out in searing detail his demotion, punishments and exile from both family and NHS and the subsequent brutal legal process that followed his illegal dismissal.
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Content ArticleIn this study published in the Quality Management in Healthcare journal, a community health organisation’s successful method of frontline staff committee engagement generated process changes that culminated in reduced medication errors and increased near misses. Continuous quality improvement initiatives supported by these committees included technical handling and administration of medication, medication reconciliation, and enhancements to standardised treatment protocols.
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Community PostWhat do hub members think about use of the term "near miss" vs "close call" vs "good catch" to describe errors that are caught before the reach or harm the patient? If you have a favorite, can you say why?
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News Article
Patients given wrong air in oxygen mix-up at hospital
Patient Safety Learning posted a news article in News
A hospital has made changes after two patients were accidentally given medical air instead of oxygen. The two incidents, which took place at the Norfolk and Norwich University Hospital (NNUH), were classed as "never events" meaning they were serious but preventable. They happened to patients in November who were being handed over to the hospital by the East of England Ambulance Service. The patients should have been given oxygen but were given medical air instead which only contains 20pc oxygen. The ambulance service said in a message to staff: "Severe harm or death can occur, if medical air is accidentally administered to patients instead of oxygen. As per NNUH's request, with immediate effect, when handing over at the NNUH, all medical equipment and oxygen should be swapped only by an emergency department doctor or registered nurse." Read full story Source: Eastern Daily Press, 2 December 2019 -
Content Article
Creating a safety culture
Claire Cox posted an article in Other countries and national agencies
A safety culture is built on trust. It empowers staff to report errors, near misses, and recognise unsafe behaviours and conditions that can put patients at risk, all of which drive improvement. This video by the Joint Commission Centre for Transforming Healthcare explains how they are engaging staff and the importance of speaking up. -
Content ArticleAnnie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without the knee-jerk blame and shame approach of old.
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Content Article
A reflective account of the culture of fear
Anonymous posted an article in Bullying and fear
This is my story of how one bad experience can lead to another. We talk a lot about patients and their safety (quite rightly so) but very rarely do we hear about the healthcare professional who is going through turmoil and their mental health. This is my story.- Posted
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Content Article
Re-consenting, an anonymous blog
Claire Cox posted an article in Consent issues
This anonymous blog high lights the vulnerability of patients, especially when it come to consent. This is a shocking account of events by a well informed patient when they were wrongly consented for a gynaecological procedure. -
Content ArticleResearchers have shown that people often miss the occurrence of an unexpected yet salient event if they are engaged in a different task, a phenomenon known as inattentional blindness. However, demonstrations of inattentional blindness have typically involved naive observers engaged in an unfamiliar task. What about expert searchers who have spent years honing their ability to detect small abnormalities in specific types of images? We asked 24 radiologists to perform a familiar lung-nodule detection task. A gorilla, 48 times the size of the average nodule, was inserted in the last case that was presented. Eighty-three percent of the radiologists did not see the gorilla. Eye tracking revealed that the majority of those who missed the gorilla looked directly at its location. Thus, even expert searchers, operating in their domain of expertise, are vulnerable to inattentional blindness.
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Content ArticleInpatient falls are one of the most common patient safety incidents reported in rehabilitation wards in Australia and can result in serious adverse patient outcomes, including permanent physical disability and occasionally death. Camden Hospital in Australia implemented a multidisciplinary review meeting (Safety Huddle) following all inpatient falls and near miss falls, which developed strategies in consultation with the patient to prevent the incident from reoccurring.
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