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Showing results for tags 'Human error'.
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Content ArticleFindings In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year. The most common errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nationally and international data, highlights an area for improvement. A varied approach to patient safety was evident on review of the corrective measures applied following the occurrence of a significant event. High efficacy corrective measures such as forcing functions, which can eliminate risk, were evident. However, in some cases, the corrective measures put in place to prevent recurrence were limited to low efficacy strategies such as re-education of staff. Undertakings should consider the risk management strategies applied to incident investigations and corrective measures to ensure they are robust and help prevent errors from reoccurring rather than punish. Overall, many of the investigation reports received by HIQA were comprehensive and showed systems based approaches to reviewing incidents. Some, however, focused on human error in isolation, without consideration of human error as a symptom of system weaknesses. Undertakings should ensure a just culture is in place where individuals feel free to report errors, assured that the response will focus on what happened, rather than who failed. This was not always evident in reports received by HIQA. Finally, it is noted that radiation incidents reported to HIQA in 2019 have involved relatively low radiation doses with limited risk to service users. The findings in this report indicate that overall the use of radiation in medicine in Ireland is generally quite safe for patients. However, radiation incidents have been reported internationally with severe detrimental effects to service users. The potential for such serious adverse events highlights the need for ongoing vigilance in relation to radiation protection and the necessity of reporting and learning frameworks. It is hoped that areas of improvement noted in this report would help reduce the likelihood of such events and drive quality improvements in safety mechanisms for medical exposures in Ireland.
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News ArticleThe Health Information and Quality Authority (HIQA) has today published an overview report on the lessons learned from notifications of significant incident events in Ireland arising from accidental or unintended medical exposures in 2019. In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year.The most common errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nationally and international data, highlights an area for improvement.John Tuffy, Regional Manager for Ionising Radiation, said “The overall findings of our report indicate that the use of radiation in medicine in Ireland is generally quite safe for patients. The incidents which were reported to HIQA during 2019 involved relatively low radiation doses which posed limited risk to service users. However, there have been radiation incidents reported internationally which resulted in severe detrimental effects to patients so ongoing vigilance and attention is required." John Tuffy, continued “As the regulator of medical exposures, HIQA has a key role in the receipt and evaluation of notifications received. While a significant event is unwanted, reporting is a key demonstrator of a positive patient safety culture. A lack of reporting does not necessarily demonstrate an absence of risk. Reporting is important, not only to ensure an undertaking is compliant but because it improves general patient safety in a service and can minimise the probability of future preventative events occurring.” Read full story Source: HIQA, 9 September 2020
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Medical error prevention (5 May 2020)
Sam posted an article in Good practice
Thomas L. Rodziewicz and John E. Hipskind explore medical error prevention in their book and conclude that: All providers (nurses, pharmacists, and physicians) must accept the inherent issues in their roles as healthcare workers that contribute to error-prone environments. Effective communication related to medical errors may foster autonomy and ultimately improve patient safety. Error reporting better serves patients and providers by mitigating their effects. Even the best clinicians make mistakes, and every practitioner should be encouraged to provide peer support to their colleagues after an adverse event occurs. Medical errors and near misses should be reported when they are discovered. Healthcare professionals are usually the first to notice a change in a patient's condition that suggests an adverse event. A cultural approach in which personal accountability results in long-term increased reporting reduces errors. -
News ArticleInquest finds Susan Warby, 57, received insulin she did not need after blood test mistakes. Hospital errors contributed to her death five weeks after bowel surgery, an inquest into her death has concluded. Susan Warby, 57, who died at West Suffolk hospital in Bury St Edmunds, was incorrectly given glucose instead of saline through an arterial line that remained in place for 36 hours and resulted in inaccurate blood test readings. She was subsequently given insulin she did not need, causing bouts of extremely low blood sugar (hypoglycemia) and the development of “a brain injury of uncertain severity”, recorded Suffolk’s senior coroner, Nigel Parsley. Speaking after the inquest was adjourned in January, Susan's husband, Jon Warby, said he was “knocked sideways completely” when he received an anonymous letter two months after her death highlighting blunders in her treatment. Doctors at the hospital were reportedly asked for fingerprints as part of the hospital’s investigation into the letter, a move described by a Unison trade union official as a “witch-hunt” designed to identify the whistleblower. Following January’s adjournment, Parsley instructed an independent expert to review the care that Warby received. Warby’s medical cause of death was recorded as multi-organ failure, with contributory causes including septicaemia, pneumonia and perforated diverticular disease, affecting the bowel. Recording a narrative conclusion, Parsley wrote: “Susan Warby died as the result of the progression of a naturally occurring illness, contributed to by unnecessary insulin treatment caused by erroneous blood test results. This, in combination with her other comorbidities, reduced her physiological reserves to fight her naturally occurring illness.” Jon Warby said in a statement: “The past two years have been incredibly difficult since losing Sue, and it is still a real struggle to come to terms with her no longer being here. The inquest has been a highly distressing time for our family, having to relive how Sue died, but we are grateful that it is over and we now have some answers as to what happened." “After learning of the errors in Sue’s care, I wanted to know how these occurred and what action was being taken to prevent any similar incidents in the future. The trust has now made a number of changes which I am pleased about.” Read full story Source: The Guardian, 7 September 2020
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Content ArticleSLIPPS 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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Content ArticleThe results, published in BMJ Safety & Quality, found that fewer moderate-severe IMG-related errors occurred with the user-tested guidelines compared with current guidelines, but this difference was not statistically significant. Significantly more simulations were completed without any IMG-related errors with the user-tested guidelines compared with current guidelines. Participants who used user-tested guidelines reported greater confidence. The authors conclude that user-testing injectable medicines guidelines reduces the number of errors and the time taken to prepare and administer intravenous medicines, while increasing staff confidence.
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Content ArticleThe full case studies document is free to download. Request a copy by completing the request form, after which you will receive a link to the document on screen and by email.
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Diagnosis: COVID Blindness (April 2020)
PatientSafetyLearning Team posted an article in Blogs
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Coronavirus: NHS staff with Covid-19 given wrong test results
Patient Safety Learning posted a news article in News
Some Welsh NHS staff with Covid-19 have been given wrong test results and were told they did not have coronavirus, BBC Wales has learned. They are among a group of ten who have been given incorrect results - including eight from Aneurin Bevan Health Board and two from elsewhere. It is not clear how many of the ten had Covid-19 and were told they did not, or vice versa. The Gwent-based heath board said the staff were contacted "immediately". It happened when a small number of test samples from a batch of 96 were attributed to the wrong patients. Read full story Source: BBC Wales, 7 April 2020 -
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