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Found 124 results
  1. Content Article
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    “Human error” resulted in a man having the wrong leg amputated at a major Austrian hospital. The error occurred when a healthcare employee marked the wrong leg for amputation during pre-surgical procedures. The mistake was not noticed anytime during the surgery, or even during the immediate postoperative period. It was recognised during a routine wound dressing change, about 48 hours postoperatively. “A disastrous combination of circumstances led to the patient’s right leg being amputated instead of his left,” the hospital’s statement said. “We would also like to affirm that we wi
  4. Content Article
    Stuck in a lift This series of blogs has been characterised by writers of great wit and wisdom, with references to Socrates, Oscar Wilde and more. As the latest incumbent, I feel a great trust has been placed upon me to maintain the standard. That I plan to completely abuse by telling you about the time I was stuck in a lift in my underpants. For the sake of probity, I should point out that they were highly respectable underpants. The sort of multi-purpose item that is sold in high-end camping shops as suitable for underwear/swimming/signal flags. That information is entirely irreleva
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    After watching the video, participants should be better prepared to: Acquire an understanding of the concept of a "medical error". Appreciate the safety movement. Understand the culture of safety. Illustrate real examples of adverse events and their sequelae. Identify a high reliability organisation.
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    Well, this sounds like I have moved from my normal citation of Greek philosophers and Classical Greek terms like ‘ergonomics’ straight through to the Avant Garde poetry of the 1950s. An error trap is an error trap. That is either profound, or Martin has got into the evidence locker again and is smoking ‘Exhibit A’. The idea I am going to advance is that an ‘error trap’ as described on the hub pages really is a simplistic trap, to trap the untrained investigator. There is, after all, a regulator of all this forensic stuff which might help here. In 2019 (when the world was simple), I said w
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    Having accurate patient information (for example, age, allergies, laboratory results) helps practitioners select medications, doses and routes of administration. One vital piece of information, the patient's weight, is especially important, because it is used to calculate the appropriate dose of a medication (for example, mg/kg, mcg/kg, mg/m2). A prescribed or dispensed medication dose can differ significantly from the appropriate dose because of missing or inaccurate patient weights. Patients in oncology treatment, patients with renal insufficiency, or who are elderly, paediatric or neon
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    In the study, Yonash and Taylor identified instances of WSS events (not including near misses) that occurred during 2015–2019 and were reported to PA-PSRS. During the five-year period, they found that 178 healthcare facilities reported a total of 368 WSS events, which was an average of 1.42 WSS events per week in Pennsylvania.They also found that 76% (278 of 368) of the WSS events contributed to or resulted in temporary harm or permanent harm to the patient. Overall, the study shows that the frequency of WSS varied according to a range of variables, including error type (e.g., wrong side,
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    How many times have you been to the drug cupboard/trolley at work and looked at it with despair? How many times have you looked at a written prescription or plan of care and were unable to read the writing? How many times have you gone into the storeroom and spent ages looking for what you want as everything looks the same or it has moved to a different spot? These are what we call error traps. It is as if you have an annoying brother/sister that is trying to catch you out! Sometimes in healthcare, no matter where you work, there are times when it is not easy to do the right thi
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    Research shows that patient complaints are significantly associated with physicians' risk management activity and lawsuits. Research also demonstrates that a small subset of physicians and surgeons in various areas of practice are associated with disproportionate shares of patient complaints. Coded and aggregated patient complaint data therefore offer a metric for identifying and promoting behavior change. Analysis of the distribution of patient complaints associated with 41 paediatric cardiac surgeons is presented as a means for helping leaders show one surgeon how her/his risk status c
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    SLIPPS is responding to the challenge to improve European patient safety competence and education. Errors, mishaps and misunderstandings are common and around 1 in 10 patients suffer avoidable harm (WHO 2014). The majority of adverse care episodes and near misses are preventable (Vlayen et al 2012) and such incidents impact upon patients, their families, health care organisations, staff and students.
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