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Found 34 results
  1. 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 sector have no “HE Recovery Protocols” on their wards (2a) This massive management error is punishable with fines and imprisonment across every other sector including Nuclear Rail Shipping etc. by the CPS here in the U.K. HE recovery protocol for ward-patient safety The patient is placed in a computerised quality-loop enabling them to acknowledge received MDT interventions by tagging their personal wristband-data back to the computer care plan. Missed interventions easily detected by the software-checklist now compellingly alarmed on-screen in front of health worker and patient. Nigh impossible to ignore, missed interventions are corrected, reducing the consequences of HE by more than a factor of ten thousand (104) (2b). Example: Opioid overdose prevention Software analyses patient's analgesic ladder. Their previously tagged opioid consumption displayed with opioid headroom warning. The patient tags acknowledging and updating the new opioid volume correctly administered. The system would have saved 450 Gosport patients 30-years ago, and currently under live investigation by Police (Operation Magenta). Conclusion Placing the ward patient in a computer driven tagged quality loop significantly reduces HE-consequences improving compliance lowering death rates adverse events bed-days and litigation. The tag system has a long-standing pedigree too. U.K. Bank customers have electronically tagged 30 million times a day, keeping accounts healthy and error free for decades. Please could colleagues on the hub help the NHS/CQC understand this established Industrial H&S concept with a view to trialling it. (Sums: 2.6m/10,000=2600 saving 2,597,400 annually?) References: [1] The cost of patient safety inaction: Why doing more of the … A .M. Alhawsawi. Patient Safety Hub 2020. [2a] The Blame Machine. R B Whittingham. ISBN 0-7506-5510-0. Industrial H&S. https://books.google.co.uk/then type “5.3 error recovery ” (page 74-75). [2b] https://books.google.co.uk/ then type “1. compelling feedback ” (page 78-79). Compelling feedback reduces HE by a factor of 10,000. Foot note: Sometimes whole industries become unwilling to look too closely at system faults and the blame machine swings into action. Pity the individual health worker not protected by management HE recovery protocols. https://books.google.co.uk/ type “The blame machine preface xii” last two paragraphs and xiii. Derek Malyon. 24.11.2020. Ward-Patient eQMS with Error Recovery Protocols.3 pdf.pdf
  2. Content Article
    There is insufficient evidence that double versus single checking of medication administration is associated with lower rates of MAEs or reduced harm. Most comparative studies fail to define or investigate the level of adherence to independent double checking, further limiting conclusions regarding effectiveness in error prevention. Higher-quality studies are needed to determine if, and in what context (eg, drug type, setting), double checking produces sufficient benefits in patient safety to warrant the considerable resources required.
  3. News Article
    Early warning scores are used in the NHS to identify patients in acute care whose health is deteriorating, but medics say it could actually be putting people in danger. The rollout of an early warning system used in hospitals to identify patients at the greatest risk of dying is based on flawed evidence, according to a study published in the BMJ which suggests that much of the research supporting the rollout of NEWS was biased and overly reliant on scores that could put patients at greater risk.. Medical researchers said problems with NHS England's National Early Warning Scores (NEWS) system had emerged "frequently" in reports on avoidable deaths. The system sees each patient given an overall score based on a number of vital signs such as heart rate, oxygen levels, blood pressure and level of consciousness. Doctors and nurses can then prioritise patients with the most urgent NEWS scores. But some professionals have argued that the system has reduced nursing duties to a checklist of tasks rather than a process of providing overall clinical assessment. Professor Alison Leary, a fellow of the Royal College of Nursing and chair of healthcare and workforce modelling at London South Bank University, told The Independent: “In our analysis of prevention of future death reports from coroners, early warning scores and misunderstanding around their use feature frequently". “It's clear that some organisations use scoring systems and a more tick box approach to care as they lack the right amount of appropriately skilled staff, mostly registered nurses.” “Early warning scores might not perform as well as expected and therefore they could have a detrimental effect on patient care,” the authors of the research conclude. “Future work should focus on following recommended approaches for developing and evaluating early warning scores, and investigating the impact and safety of using these scores in clinical practice.” Read full story Source: The Independent, 21 May 2020
  4. Content Article
    This document outlines ten key guidance points that designers of procedures should address at all stages of its development, implementation and review: 1. What is a work procedure? 2. Ensure a procedure is needed 3. Involve the whole team 4. Identify the hazards 5. Capture work-as-done 6. Make it easy to follow 7. Test it out 8. Train people 9. Put it into practice 10. Keep it under review. An explanation of the discipline of Human Factors and Ergonomics (HFE) and the sub-discipline of human-centred design are also provided.
  5. 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.
  6. 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 suddenly we are in the midst of a violent storm and we need to utilise that information! We ardently listen to the attendants instructions and pray for the captain to land the plane safely, which he does with great skill! I now want to link this scenario to the care of our patients in the operating theatre. They are also on a journey to a destination of a safe recovery and they depend on the consultants and the team to get them there safely. Despite being routine, we need to do all the safety checks for each patient and follow the WHO Surgical Safety Checklist as it is written: ask all the questions, involve all members of the surgical team, even do the fire risk assessment score if it is implemented in your theatre. The pilot of that flight during Storm Dennis certainly did not think he was on a routine flight. He had a huge responsibility for the lives of his crew and many passengers! We can only operate on one patient at a time. Always remember, even though the operation may be routine for us, it may be the first time for the patient – so let's make it a safe journey for each patient. Do it right all the time!
  7. 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 especially important and should be recorded.
  8. Content Article
    Eastern AHSN provided Quality Improvement (QI) coaching to the nurses employed by South Norfolk Clinical Commissioning Group (CCG) to work with residential and nursing homes across central Norfolk and Waveney to support the implementation of the checklist approach. The overarching aim was to reduce avoidable admissions to hospital from care homes. The Eastern AHSN believes this successful project is an easily replicable approach to the improved management or prevention of UTI and can directly impact by not only improving patient care with the added benefit of admission avoidance and reducing unnecessary clinical call outs. Successful results and benefits: At the time of writing, 700 staff from 104 care homes across Norfolk have been trained in the management and prevention of UTI and how to complete the UTI checklist. Unplanned emergency admissions have reduced by 22% and a reduction in antibiotic prescribing has been seen within this cohort of care homes. Staff reported increased confidence in the management and prevention of UTI. Data from the checklists highlighted that a lot of UTIs were related to catheter management and obtaining samples from the bag, which became increasingly preventable from the change in treatment. Care workers were assuming residents had an UTI, but after the teaching sessions they realised it may be dehydration that could present the same symptoms and commenced re-hydration. If an UTI is suspected then the staff were taught to initially think dehydration and to increase fluid intake then to reassess the patient prior to making call outs. Care homes are not now doing routine urine dipsticks or using urine dipsticks as a diagnostic test to diagnose UTI’s which has improved our diagnosis of UTI. Feedback from care homes and primary care has been very positive with one care home manager emailing to say: “The UTI checklist is definitely used at our nursing home and we have noticed a positive difference since we started. Thank you for your support.”
  9. Content Article
    What will I learn? Within the toolkit you will find: The SBAR (Situation-Background-Assessment-Recommendation) technique, which provides a framework for communication between members of the health care team about a patient's condition. Action Hierarchy, a component of RCA2 that will assist teams in identifying which actions will have the strongest effect for successful and sustained system improvement. A daily huddle agenda, which gives teams a way to proactively manage quality and safety. Failure Modes and Effects Analysis (FMEA): also used in Lean management and Six Sigma, FMEA is a systematic, proactive method for identifying potential risks and their impact.
  10. Content Article
    “One small step for man ... “ 50 years on – we all recognise this phrase that accompanied one of the most famous descents in history: Neil Armstrong’s emergence from the lunar module toward his first step on the moon. The Apollo 11 moon landing represents an unparalleled accomplishment. Its characteristics resonate with patient safety professionals who look to space for inspiration. The Apollo programme experienced both triumphant achievement and catastrophic failure. The effort learned from mistakes, embraced teamwork, and considered human factors as part of its domain. Its workforce remained focused on a single goal. The effort embodied commitment, complicatedness and complexity. The 50th anniversary of these victories provides compelling parallels for error reduction efforts active today in healthcare in the US: Organisational learning systems NASA (National Aeronautics and Space Administration) is a learning system. Learning systems are developed and nurtured through common goals, leadership commitment and resource sustainability. They thrive through action generated by the application of data, evidence and knowledge. Likewise, the US Agency for Healthcare Research and Quality (AHRQ) has partnered with the US-based hospital and healthcare accreditation organisation, The Joint Commission, to disseminate analysed evidence compiled by the Evidence-based Practice Center (EPC) programme. These organisations are working together to transfer what is known into an actionable form through a series of articles to enhance the use of better practice and learning on the frontline. This programme and the article series are introduced in a recent commentary on the project. Coordinated action The Keystone Center represents the culmination of the work of patient safety’s own Neil Armstrong – Dr Peter Pronovost, known for his otherworldly (at the time) commitment to the checklist intervention. The Keystone Center initially coordinated and collected data to guide the implementation of the checklist concept in 70 intensive care units across the state of Michigan. Now the Center serves as the state’s mission control for hospital patient safety and quality. Leaders there raise awareness of success through the Speak-Up! award programme that acknowledges frontline healthcare staff for voicing their concerns and making care safer. The Center enables sharing of concerns that result in cost savings due to harm avoidance. A push in the right direction The Apollo programme applied technical sophistication, engineering and know-how to land a man on the moon and return safely to Earth within a decade. No small feat! Despite that imperative, both the module and the space programme needed a little boost now and again to get out of Earth’s orbit to complete its momentous undertaking. Patient safety has a similar call motivating its work – zero preventable harm. Some aim for ‘zero harm’ but is this achievable? Healthcare is very complex with multiple machine/human/machine interfaces. Clinicians, leadership and organisations still need a boost to design and use technology and data to support the workforce to improve care at the bedside. The mission-driven, Boston-based Betsy Lehman Center builds on a strong desire to prevent failures similar to those that took the life of its namesake – Betsy Lehman – the Boston Globe reporter who died in 1994 due to medication errors. The Center is a state agency that serves as mission control for its constituents. To help healthcare in Massachusetts move its safety work beyond the comfort of the status quo, they have recently convened a consortium to propel existing programmes towards new and aspirational achievement. On the dark side of the moon Of course, the Apollo programme suffered setback and tragedy. While I want to highlight successes in my Letter from America, I will also share stories of struggle to foster learning from what doesn’t work. News and narrative will often remind us of why continued work on safety improvement is fundamental. Diagnostic error is prevalent. A recent analysis of closed US medical malpractice claims found that delayed or missed diagnoses in three primary clinical areas – vascular events (such as strokes), infections (like sepsis) and cancer – substantially resulted in disability or death. You can take that to your mission control to motivate data collection, teamwork and effort to focus on diagnostic improvement in practice. Transparency is messy. The revelation of Neil Armstrong’s reported death in 2012 due to substandard medical care is sad for all kinds of reasons. It underscores persistent cultural influences that reduce the sharing of information related to poor care. This minimises our opportunity to learn from failure and support patients, families and clinicians involved in error. Organisational resistance to transparency about mistakes and the messiness of openness are challenges... even when the incident involves a patient with less name recognition. The Apollo programme and the 1969 lunar landing remains inspirational to this day. It behooves all of us who dream of contributing to something we once felt was impossible to engender the right spirit, resources and commitment to help get it done. The learning required for such accomplishment takes time, a culture that supports discussion and recognition of success. If we embrace contribution, collaboration and community, our small steps have the potential to contribute to the “giant leap” forward – to help us take off, realise achievement and return our patients safely home.
  11. Content Article
    Prompt cards can be used by all members of the Emergency Department Team. If used correctly they will improve patient safety and reduce human factor errors. Prompt Card Version 3.0.pptx
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