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Showing results for tags 'Human error'.
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Patient Safety Authority: Wrong-site surgery
Patient Safety Learning posted an article in Surgery
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Error traps: Let’s raise awareness
Patient Safety Learning posted an article in Error traps
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 thing. Often, we know about these traps and have become used to living with them. We may set up processes that mitigate us making the mistake. This is great, but is this addressing the problem? We have diagnosed the problem, but we haven’t stopped that potential error from happening again. In the world of ergonomics it is the forcing function commonly cited in human factors case studies as recommendations for error-prevention in health and safety contexts. It means forcing users to do something in a certain way in order to proceed on a journey. A great example is how banks have prevented customers from leaving their card in the ATM. The forcing function is that the machine will bleep to prompt the customer to remove the card from the machine before the money is released. This prevents cards being left in the machine. Whereas if there was just a sign saying ‘remember to take your card’ there will always be a risk that people will not read the sign – the sign may fall off or be removed or it will become invisible as people rush about in their daily lives. So how can we solve these error traps in health and social care? We have created an error trap gallery for hub members to share examples of error traps they have come across and also examples of where action has been take and worked. View our error trap gallery and share your examples Reference 1. Steve Highley. An Encounter with an Error Trap. 6 August 2015. https://www.hastam.co.uk/an-encounter-with-an-error-trap/- Posted
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Content ArticleAdvice for healthcare professionals do not use glucose-containing solutions as infusates for maintaining arterial line patency, unless there are no suitable alternatives saline infusions are recommended as the flush solution for arterial lines, to minimise the risk of incorrect blood glucose estimation and inappropriate insulin administration if samples are drawn from arterial lines for estimation of biochemistry, a minimum volume of three times the dead space of the cannula system should be discarded first to avoid contamination[^4] remain vigilant when selecting a solution for arterial line infusate. Similarities between glucose and saline solution bags means that confusion may occur ensure that the arterial infusion line length is kept to the minimum necessary.
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An encounter with an error trap by Steve Highley (6 August 2015)
Sam posted an article in Error traps
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Ontario woman finds needle in her spine 16 years after giving birth
Patient Safety Learning posted a news article in News
When the pain in her shoulders and weakness in her right leg started two years ago, Giovanna Ippolito thought it was just part of getting older — that's until the 46-year-old's doctor ordered an X-ray that showed a five-centimetre long, broken needle embedded in her spine. It was a medical error that took more than a decade to discover — after medical staff at the time failed to report it. Exactly when the needle was left in Ippolito's spine is unclear, but she says she's only had something injected into her back twice — during the birth of her son in 2002 and her daughter in 2004. Ippolito says she believes the needle broke off when medical staff at Mackenzie Richmond Hill Hospital in nearby Richmond Hill (called York Central Hospital at the time) administered a spinal block or an epidural during one of the births. She's now locked in a battle with the hospital for answers and accountability. But experts say, with a system that's stacked against Canadians harmed by medical errors, it's likely no one will have to take responsibility. More than 132,000 patients experienced some kind of medical harm — something both preventable and serious enough to require treatment or a longer hospital stay — in 2018-19, according to the Canadian Institute for Health Information, an independent, not-for-profit organization that collects information on the country's health systems. Read full story Source: CBC, 5 October 2020 -
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The human error trap (7 June 2017)
Patient Safety Learning posted an article in Error traps
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Content ArticleResearch 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 compares with peers. The paper describes a specific plan and reliable process by which medical group/centre colleagues and leaders may: address lapses in professionalism and performance; follow-up to promote professionalism, professional accountability, quality, and a safety culture; and reduce risk.
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News ArticleAn anaesthetist who had been drinking before an emergency caesarean that led to the death of a British woman should serve the maximum three years in jail if convicted and should be banned from working as a doctor, a French prosecutor has demanded. Helga Wauters is on trial in Pau, south-west France, for the manslaughter of Xynthia Hawke in 2014. She is accused of starving Hawke of oxygen for up to an hour after pushing a ventilation tube into the wrong passageway. Orlane Yaouang, prosecuting, described the scene in the operating theatre when Hawke turned blue as “carnage” and spoke of the “surreal situation” in which the panicked hospital staff called the emergency services. Read full story Source: The Guardian, 9 October 2020
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Community PostWe should all strive to keep antibiotics working for our NHS surgeons and future generations, by decreasing antibiotic use in medicine. It is mums themselves who could dramatically decrease antibiotic use, in the only medical specialty where this is possible - in obstetrics - by keeping skin intact; by being informed of the 10cm diameter that 'Aniball' and 'Epi-no Delphine Plus' birth facilitating devices, the mechanical version of Antenatal Perineal Massage, achieve by skin expansion (much like by 'earlobe skin expanders') prior to birth, for back of baby's head. This enables a normal birth for many more babies by shortening birth, with no cutting (episiotomies) or tearing, and much fewer Caesarean sections, as each Caesarean section requires antibiotics to be injected into mum, to kill any bacteria, which might have invaded a skin cell, from being implanted with that skin cell, deep into the wall of the uterus, by the surgeon's knife. There are around 750,000 births in the UK alone and three-quarters of mums are damaged during birth and at risk of developing infection; so a dramatic decrease in antibiotic use is possible. Empowering mums with knowledge; that both the skin and the coats of the pelvic floor muscles, which form the floor of the lower tummy, can be stretched painlessly, in preparation of birth, from the 26th week of pregnancy, so a gentler, kinder birth for both baby and mum becomes possible by decreasing risky obstetric interventions. Muscle can be stretched to 3 times its original length, if stretched painlessly over 6 or more occasions, and still retains its ability to recoil back, contracting to its original length. So there is no damage to mum. Baby's delicate head is not used to achieve this 'birth canal widening', because Antenatal Perineal Massage or Aniball or Epi-no Delphine Plus have already achieved this prior to the start of birth. In birth this stretching is rushed within the last 2 hours of birth, with risk of avulsion of pelvic floor muscle fibres from the pubic bone and risk of skin tearing or the need for episiotomy. The overlying skin will likewise stretch without tearing if done over 6 or more occasions. The maximal opening in the outlet or lower part of the pelvis is 10cm diameter, so 10cm diameter is the goal of the birth aiding devices and 'Antenatal Perineal Massage' or 'Birth Canal Widening' - opening doors for baby maximally. The mother reviews on 'Aniball' and 'Epi-no Delphine Plus' are impressive: Wanda Klaman, a first time mum, gives birth at nearly 42 weeks to a 4.4kg baby, with no need for episiotomy or forceps; Sophie of London, avoids episiotomy, when forceps are used to aid delivery for her baby who lays across her tummy - transverse lay, because the skin at this opening is so stretchy thanks to the birth facilitating devices. Cochrane Collaborate Report on Antenatal Massage https://pubmed.ncbi.nlm.nih.gov/23633325/ https://www.dailymail.co.uk/news/article-7450045/Fears-infections-pandemic-grow-NINETEEN-new-superbugs-discovered-UK.html https://www.mirror.co.uk/news/uk-news/mistakes-maternity-wards-setting-nhs-22702909
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Community PostSee Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.
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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
