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Found 48 results
  1. News Article
    The Care Quality Commission has ordered immediate improvements to a trust after it reported six never events inside eight months. The watchdog has issued a warning notice to Royal Cornwall Hospitals Trust after it carried out an announced inspection which focused on the trust’s surgical care group – where six never events had occurred between February and October last year. In November, HSJ reported that a total of eight never events had been recorded in 2020, with trust chief executive Kate Shields saying it had raised fears the trust had not fully embedded safety improvements initi
  2. Community Post
    Overview Human error (HE) in global medicine kills 2.6 million annually placing patient safety on the G20 Summit (1). Solutions available (a) more staff training dominated by a HE-rate of about one error in 200 tasks and (b) a simple computer system used by high reliability organisations such as Banking with zero HE. With 70% of adverse events occurring on wards, patients should electronically acknowledge each intervention with their wristband-data. Missed interventions now detectable are compellingly alarmed reducing the consequences of HE 10,000 fold. Problem: The Healthcare s
  3. Content Article
    In this book, Atul Gawande makes a compelling argument for the checklist, which he believes to be the most promising method available in surmounting failure. Whether you're following a recipe, investing millions of dollars in a company or building a skyscraper, the checklist is an essential tool in virtually every area of our lives and Gawande explains how breaking down complex, high pressure tasks into small steps can radically improve everything from airline safety to heart surgery survival rates.
  4. Content Article
    The anaesthetist has a primary responsibility to understand the function of the anaesthetic equipment and check it before use. Anaesthetists should not use equipment unless they have been trained in its use and are competent to do so. A self-inflating bag should be immediately available in any location where anaesthesia is given. A two-bag test should be performed after the breathing system, vaporisers and ventilator have been individually checked. A record should be kept with the anaesthetic machine that these checks have been carried out. The ‘first user’ check, after servicing, is especiall
  5. Content Article
    Recently Dr Peter Brennan tweeted a video of a plane landing at Heathrow airport during Storm Dennis. I looked at this with emotion, and with hundreds of in-flight safety information, human factors, communication and interpersonal skills running through my head. I thought of the pilot and his crew, the cabin crew attendants and the passengers, and how scared and worried they would have felt. On a flight, the attendants will take us through the safety procedures before take off. We are all guilty, I am sure, of partly listening because it is routine and we have heard it all before. Then s
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