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Showing results for tags 'System safety'.
Found 518 results
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News ArticlePatients are at risk of a missed cancer diagnosis due to a reliance on paper records, an NHS trust has admitted after a man died due to his tumour being overlooked. Michael Lane, 50, from Shrewsbury, was “failed” by Shrewsbury and Telford Hospital Trust, his family has said after his cancer scan result was misplaced leaving him with a growing kidney tumour for 10 years. The trust is yet to fully launch an electronic record system a year after an investigation into Mr Lane’s death warned other patients were at risk due to the gap in paper records. Mr Lane went into Shrewsbury and Telford Hospital for a scan following a referral for suspected cancer in 2011. The radiographer flagged a small tumour but the scan was overlooked, placed within his paper records and never reported as being a concern. In an investigation report carried out by the trust in May 2021, seen by The Independent, the hospital admitted that had his tumour been seen and operated on earlier he may have survived. The report also admitted there were ongoing risks within the trust due to gaps in its electronic records system. It said: “The implementation of an IT solution will not prevent sad cases such as that of Mr Lane where the scan report that was missed took place before the widespread availability of such systems, however, it is clear that until we have an electronic requesting and sign-off system we remain at risk of new cases of missed results and harm occurring as a result of the ongoing reliance of paper-based results.” Read full story Source: The Independent, 17 July 2022
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News Article
Medical expert witnesses ‘should not scapegoat doctors’
Patient Safety Learning posted a news article in News
Medical experts in cases involving doctors should have a mandatory duty to consider systems issues such as inadequate staffing levels to avoid them being scapegoated for wider failures, the Medical Protection Society (MPS) has said. The MPS, which supports the the professional interests of more than 300,000 healthcare professionals around the world, says medical expert reports focus on scrutinising the actions of the individual doctor even when failings are a result of the setting in which they work. Its report on the issue, shared with the Guardian before publication, points out that for doctors “adverse opinion can lead to loss of career or liberty”. It references the case of Dr Hadiza Bawa-Garba who was convicted of gross negligence manslaughter in 2015 and handed a 24-month suspended sentence for her part in the death of six-year-old Jack Adcock from sepsis. She was later struck off by the General Medical Council before the court of appeal overturned the GMC’s decision. Dr Rob Hendry, the MPS medical director, said: “In giving an opinion on whether or not the care provided by a doctor has fallen short of a reasonable standard, it would seem fair to the doctor that the medical expert considers all relevant circumstances. Any individual performance concerns must of course be addressed, but doctors should not be scapegoats for the failings of the settings in which they work. Sadly, we see this all too often in cases against doctors … “Many expert reports focus solely on the actions of the individual without considering the wider context. In reality, patient harm arising from medical error is rarely attributable to the actions of a single individual. Inadequate staffing levels, lack of resources, or faulty IT systems are just some issues which can contribute to adverse incidents. Doctors confront these issues every day and have little influence over them.” Read full story Source: The Guardian, 18 July 2022 -
Content ArticleAn increasing number of healthcare artificial intelligence (AI) applications are in development or already in use, but the safety impact of using AI in healthcare is largely unknown. This qualitative study in the journal Safety Science aimed to explore how different stakeholders (patients, hospital staff, technology developers and regulators) think about safety and the safety assurance of healthcare AI. Through a series of interviews, the authors assessed stakeholder perceptions of an AI-based infusion pump in the intensive care unit. Participants expressed perceptions about: the potential impact of healthcare AI requirements for human-AI interaction safety assurance practices and regulatory frameworks for AI and the gaps that exist how incidents involving AI should be managed. The authors concluded that there is currently a technology-centric focus on AI safety, and a wider systems approach is needed. They also identified a need for greater awareness of existing standards and best practice among technology developers.
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News Article
Northern Ireland: Serious adverse incidents 'likely to be repeated'
Patient Safety Learning posted a news article in News
Health Minister Robin Swann has announced plans to improve the review process for serious adverse incidents (SAI) in Northern Ireland's health and social care system. The reviews take place after unintended incidents of harm and ensure improvements are made. The Regulation and Quality Improvement Authority (RQIA) was commissioned to examine the system's effectiveness. It found the process was not "sufficiently robust". In the RQIA report, the independent body found that "neither the SAI review process nor its implementation is sufficiently robust to consistently enable an understanding of what factors, both systems and people, have led to a patient or service user coming to harm". It added: "The reality is that similar situations, where events leading to harm have been inadequately investigated and examples of recognised good practice have not been followed, have been and are likely to be repeated in current practice." It identified failures in the SAI procedure, including failures to: Answer patient and family questions. Determine where safety breaches have occurred. Achieve a systemic understanding of those safety breaches. Design recommendations and action plans to reduce the opportunity for the same or similar safety breaches in future. Read full story Source: BBC News, 7 July 2022 -
Event
Designing complex system
Patient Safety Learning posted an event in Community Calendar
untilThis free webinar from the Chartered Institute of Ergonomics and Human Factors explores how to apply human factors standards to the design of complex systems. You’ll find out about the benefits, pitfalls and challenges of using standards. You’ll hear about a step-by-step approach to finding solutions in a real-world example of a truly complex system. Register -
Content ArticleThe 2022 conference returned to Parliament on Thursday 19 May and was hosted by Taiwo Owatemi MP. Entitled “The Road to Resilience”, it explored the steps that will need to be taken in the years to come to continue the momentum seen during the pandemic around the key role of HealthTech and make the healthcare system more resilient for its staff and patients. Featuring keynote speakers Sam Roberts, CEO at NICE & Lord Kamall, Minister for Technology, Innovation and Life Sciences, the conference brought together key health sector stakeholders, providing insights into the direction of UK health care, its recovery following the pandemic & how technology can play a vital role in enhancing the health system moving forward. View the recording of the conference below.
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Content ArticleThis webinar by the Institute for Safe Medication Practices is aimed at healthcare providers and patient safety specialists. The conversation covers lessons learned in the aftermath of a fatal medication error and looks at common, yet often unresolved, system vulnerabilities. It also examines key strategies and priorities needed to advance an organisation's safety journey.
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Event
Creating safe systems
Patient Safety Learning posted an event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on risk and behaviour to improve patient safety. Key learning objectives: evaluating risk using mapping techniques safety interventions behaviour assessing safety culture The course is facilitated by Perbinder Grewal, a General & Vascular Surgeon, Human Factors & Patient Safety Trainer, and Emotional Intelligence Practitioner; leads on medical education both locally and nationally; Member of the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh; formerly lead for e-learning for healthcare for the Royal College of Surgeons of England; experienced trainer and coach who uses new insights to develop patient safety, staff engagement and psychological safety; has Postgraduate Certificates in Leadership and Coaching. Register -
Content ArticleThis Chartered Institute of Ergonomics and Human Factors (CIEHF) webinar explores near misses in three different sectors and how controls can, or cannot, be developed to prevent future events.
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on errors and designing system-based solutions to improve patient safety. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-based-solutions-patient-safety-masterclass or email aman@hc-uk.org.uk hub members receive a 20% discount code. Please email info@pslhub.org for a discount code.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Mark talks to us about how he came to work in healthcare, the vital role of safety scientists and human factors specialists in improving patient safety, and the challenges involved in integrating new technologies into the health system. -
Content ArticleIn this Editorial for the journal Midwifery, maternity experts come together to respond to the Ockenden review and discuss what went wrong and what needs to happen now.
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Content ArticleRecent years have seen a surge in interest in the study of resilience in medical professionals. Concern has been expressed about the psychological wellbeing of doctors in general and of surgeons specifically, with increasing individual doctors’ resilience being suggested as a possible solution.1 However, there are potential risks as well as benefits to this focus on individual resilience. This article from Bolderston et al. explores both sides of the resilience coin, and considers potentially helpful ways of addressing psychological wellbeing and resilience in surgeons, including the development of an Acceptance and Commitment Therapy-based intervention.
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Content ArticleIn May 2022, the National Steering Committee for Patient Safety (NSC) issued the Declaration to Advance Patient Safety to urge health care leaders across the continuum of care to recommit to advancing patient and workforce safety. The NSC called for immediate action to address safety from a total systems approach, as presented in the National Action Plan to Advance Patient Safety, and implored leaders to adopt safety as a core value and foster collective action to uphold this value.
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News Article
ECRI publicly supports IHI Declaration to Advance Patient Safety
Patient Safety Learning posted a news article in News
ECRI, the nation's largest patient safety organization, announces its unity with the United States' top safety experts in calling for a total systems approach to safety, a theme that was the central focus at the May 2022 Institute for Healthcare Improvement (IHI) Patient Safety Congress. During its annual convening of national safety leaders, IHI leadership announced its Declaration to Advance Patient Safety, an initiative focused on addressing safety from a total systems approach, as presented in the 2020 National Action Plan to Advance Patient Safety. "As a member of the National Steering Committee for Patient Safety that created the National Action Plan to Advance Patient Safety, ECRI fully supports this renewed call to action as outlined in the recent Declaration," states Chief Medical Officer Dheerendra Kommala, MD. "ECRI, the most trusted voice in healthcare, is in a unique position to deliver a comprehensive, robust solution that reduces preventable harm." ECRI's total system approach to advancing safety includes the design and implementation of a proactive, coordinated strategy to establish healthcare safety processes that impact patients, families, visitors, and healthcare workers across the continuum of care. Read full story Source: CISION, 26 May 2022 -
Content ArticleThis white paper is intended for non-specialists who may have little or no professional background in human factors and ergonomics but who are influential in the way decisions are made about the development and use of technology. The knowledge and guidance it contains is based on both fundamental scientific and applied research, as well as from deep study and learning from adverse events. The paper is based around nine principles that provide an easy-to-follow guide to human factors issues which need to be addressed when developing and implementing highly automated systems.
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Content ArticleThis document is a short introduction to systems thinking for civil servants. It is one component of a suite of documents that aims to act as a springboard into systems thinking for civil servants unfamiliar with this approach.
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News Article
'I will never be the same': RaDonda Vaught speaks out after sentencing
Patient Safety Learning posted a news article in News
RaDonda Vaught has spoken out about her criminal case for the first time last week in an exclusive interview with ABC News. Ms. Vaught, 38, was sentenced to three years of supervised probation on 13 May. She was convicted of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 after overriding an electronic medical cabinet as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. The error, in which vecuronium, a powerful paralyser, was administered instead of the sedative Versed, led to the death of 75-year-old Charlene Murphey. "I will never be the same person," Ms. Vaught told ABC News, "It's really hard to be happy about something without immediately feeling guilty. She could still be alive, with her family. Even with all the system errors, the nurse is the last to check." Ms. Vaught immediately took responsibility for the medication error after it occurred but contends that her actions alone did not cause the error. Her case has spurred an outcry from nurses across the country, many of whom have expressed concerns about the likelihood of similar mistakes under increasingly difficult working conditions. "So many things had to line up incorrectly for this error to have happened, and my actions were not alone in that," Ms. Vaught said. When Ms. Pilgrim asked her if she felt like a scapegoat, Ms. Vaught said, "I think the whole world feels like I was a scapegoat." "There's a fine line between blame and responsibility, and in healthcare, we don't blame," she said. "I'm responsible for what I failed to do. Vanderbilt is responsible for what they failed to do." Read full story Source: Becker's Hospital Review, 23 May 2022 -
Content ArticleOne box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable – does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture.
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Content Article"Shaming and punishing healthcare workers when an incident occurs sets a dangerous precedent for the industry. This will lead to a culture where healthcare workers avoid reporting near misses or errors for fear of repercussions, allowing process inefficiencies and systemic problems to occur." In this letter, Michael Ramsay, CEO of the Patient Safety Movement Foundation, highlights the negative ways in which criminalising healthcare workers who make mistakes will affect patient safety. He refers to the case of RaDonda Vaught, a nurse who was convicted of criminally negligent manslaughter in March 2022 for a medication error made while working at Vanderbilt University Medical Center in Nashville.
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Content ArticleEZDrugID is a campaign to improve the distinctiveness of medication packaging set up by a group of healthcare workers. Inadequate standards around medication packaging mean that medications with very different actions are sometimes packaged in a very similar way causing "look-alike drugs”. This can lead to errors and serious harm to patients if the wrong drug is mistakenly used. The EZDrugID website contains information about their campaigns to maximise distinctiveness of different medications as well as a "lookalikes" gallery. See also: the hub's error traps gallery The medication safety area of the hub
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Content ArticleDr Robert D. Glatter, medical advisor for Medscape Emergency Medicine, Dr Megan Ranney, professor of emergency medicine and the academic dean at Brown University School of Public Health and Dr Jane Barnsteiner, emeritus professor at the University of Pennsylvania School of Nursing, discuss the tragic case involving RaDonda Vaught, who was an ICU nurse who was recently convicted in Tennessee of criminally negligent homicide and gross neglect following a medical error due to administration of the wrong medication that led to a patient's death.
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Content ArticleAcciMap graphically maps the multiple contributing factors to an accident and their inter-relationships onto the following six levels: Government policy and budgeting. Regulatory bodies and associations. Local health economy planning and budgeting (including hospital management). Technical and operational management. Events, processes and conditions. Outcomes.
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Content ArticlePresentation on the of theme of prevention of medication error from Philip A Routledge and James Coulson (All Wales Therapeutics and Toxicology Centre). Presentation available as slides a written transcript.
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Content ArticleThe delivery of safe and effective healthcare to paediatric and neonatal patients presents unique challenges to the medication-use system. The diversity of patients within this population and the consequences of ontogeny on pharmacokinetics and pharmacodynamics directly impact the safe use of medications in children and increase the risk of adverse drug events. This review from Elkeshawi et al. will explore the medication-use system for hospitalised children and neonates, discuss vulnerabilities within this system, and provide examples of advancements made to improve the paediatric medication-use system.
