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Showing results for tags 'Human error'.
Found 204 results
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Content ArticleThe authors performed a content analysis of 126 investigation reports from a multi-site NHS trust and used a HFACS-based framework that was modified through inductive analysis of the data. Using the modified HFACS framework, ‘unsafe actions’ were the most commonly identified hierarchical level of contributory factors in investigation reports, which were identified 282 times across 99 (79%) incidents. ‘Preconditions to unsafe acts’ (identified 223 times in 91 (72%) incidents) included miscommunication and environmental factors. Supervisory factors were identified 73 times across 40 (31%) i
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News Article
Nurse struck off for failing to dispense morphine
Patient Safety Learning posted a news article in News
A nurse in Somerset has been struck off after she failed to give morphine to a patient before they underwent surgery. Amanda-Jane Price had been suspended from front-line duties since the incident in March 2019. The Nursing and Midwifery Council ruled that Miss Price had been "dishonest" with her colleagues and her ability to practice medicine safely was "impaired". Miss Price had been a nurse at Musgrove Park Hospital in Taunton since 2018. On 31 March 2019, Miss Price did not administer morphine to an individual in her care, falsely recording in her notes that morphine had bee -
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Saturday 17 September 2022 marks the fourth annual World Patient Safety Day. This event was established by World Health Organization (WHO) as a day to call for global solidarity and concerted action to improve patient safety. It aims to bring together patients, families, carers, healthcare professionals and policymakers to show their commitment to patient safety. Avoidable harm in health and social care What is patient safety? Simply put, patient safety is concerned with avoiding unintended harm to people during their care and treatment. WHO describes it as follows: “Patient safe -
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A medication error is defined as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer,” according to the National Coordinating Council for Medication Error Reporting and Prevention. An estimated 237 million medication errors occur in the NHS in England every year.[1] This number represents the sum of medication errors over all stages of the medication use process. Most errors occur during drug administration (54%), followed by prescribing (21%) and dispensi -
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Content ArticleTo share learning from clinical negligence claims with healthcare professionals, NHS Resolution has now published a suite of six information leaflets relating to medication errors. The ‘Did You Know’ series covers: Maternity Heparin and anticoagulants Extravasation High-level medication errors General Practice medication errors Anti-infective medication errors
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Content ArticleThe mission of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is to maximise the safe use of medications and to increase awareness of medication errors through open communication, increased reporting and promotion of medication error prevention strategies. Goals Stimulate the development and use of reporting and evaluation systems by individual health care organisations. Stimulate reporting to a national system for review, analysis, and development of recommendations to reduce and ultimately prevent medication errors. Examine
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Content ArticlePatients for Patient Safety (PFPSUS) is a network of people and organisations aligned with the World Health Organization (WHO) and focused on making healthcare safe in the United States. In this article they explain why Vanderbilt University should be held accountable for their faults. PFPSUS have requested that the U.S. Office of the Inspector General investigate Vanderbilt, the Tennessee Department of Health and CMS to determine if they followed appropriate laws and procedures related to the reporting of this error. Among the questions posed are: Did the Tennessee Departm
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News Article
Family welcomes new guidance to prevent breathing tube deaths
Patient Safety Learning posted a news article in News
A grieving family has welcomed new guidance to try to prevent a common surgical procedure from going wrong and causing deaths. Oesophageal intubation occurs when a breathing tube is placed into the oesophagus, the tube leading to the stomach, instead of the trachea, the tube leading to the windpipe. It can lead to brain damage or death if not spotted promptly. Glenda Logsdail died at Milton Keynes University Hospital in 2020 after a breathing tube was accidentally inserted into her oesophagus. The 60-year-old radiographer was being prepared for an appendicitis operation when the -
Content ArticleKey recommendations Exhaled carbon dioxide monitoring and pulse oximetry should be available and used for all episodes of airway management. Routine use of a videolaryngoscope is recommended whenever feasible. At each attempt at laryngoscopy, the airway operator is encouraged to verbalise the view obtained. The airway operator and assistant should each verbalise whether ‘sustained exhaled carbon dioxide’ and adequate oxygen saturation are present. Inability to detect sustained exhaled carbon dioxide requires oesophageal intubation to be actively excluded. T
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Content ArticleDid you know? Key causes of anti-infective medication error claims: Failure to check allergy status. Failure to cross-check the ingredients of a medication against allergy status. Failure to adjust dose of medication to the patient’s weight. Failure to adjust dose of medication according to renal function. What can you do? When prescribing antibiotics, refer to the British National Formulary (BNF) for guidance on adjusting dosages according to patient weight, kidney function and the frequency of monitoring. Refer to the traffc light system for
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Content ArticleArterial lines are routinely fitted for severely ill patients in critical care and are flushed with a solution to maintain patency, and ensure that blood does not clot in the line. Saline is recommended as the flush solution for arterial lines. There is a known patient safety risk in connection with this where glucose solutions being inadvertently and incorrectly used to flush arterial lines. This has led to inaccuracies in blood glucose measurements, which resulted in unnecessary administration of insulin and subsequent cases of hypoglycaemia, some of which have been fatal. Findings
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We need to fix it (HindSite, 2021/22)
Sam posted an article in Digital health and care service provision
Key points Digital technology supports everything we do in safety-critical industries. There are also hidden digital problems that affect everything we do, and things will go wrong. IT-related problems can have significant consequences for justice, as well as safety and security. The formal qualifications and relevant experience required for system designers in safety-critical sectors are often not specified in the way that they are for front-line staff. We have to manage digital risks more effectively to prevent associated incidents and even miscarriages of just -
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Doctor admits killing patient in botched routine procedure
Patient Safety Learning posted a news article in News
A mother was killed at her hospital appointment by a doctor who botched a routine procedure, a court has heard. Dr Isyaka Mamman, 85, was responsible for a series of critical incidents before the fatal appointment, Manchester Crown Court heard. Mamman, who admitted gross negligence manslaughter, had already been sacked by medical watchdogs for lying about his age but was re-employed by the Royal Oldham Hospital. He is due to be sentenced on Tuesday. Mother-of-three Shahida Parveen, 48, had gone to hospital with her husband for investigations into possible myeloproliferative -
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Impact of adverse events on surgeons (April 2022)
Patient Safety Learning posted an article in Surgery
Contrary to existing work, this study distinguishes error from complication, includes a measure of event severity and explores the impact of adverse events across a range of outcomes. The extent to which surgeons feel negative following adverse events is striking: nearly half of participants reported becoming more anxious, 40% sleeping worse, a third struggling to cope with anger or irritability, and over 10% reporting depression. The frequency of post-traumatic stress symptomatology illustrates the profound impact of adverse events. The study suggests surgeons do not feel prepared f
