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Found 318 results
  1. Content Article
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    Email rduh.qit@nhs,net to book a place.
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    Articles and themes in this issue Speak up... a powerful psychological safety indicator (Amy Edmonson) Empty bags or to be filled? An article about medication safety by the mother of a person with autism living in adult residence Patient safety report: Medstar health quality and safety vision A bird in the hand is worth two in the bush. By a mobile intensive care unit composed of a nurse, an ED doctor and a driver A vision of the health system in 10 years (Johannes Wacker) Implementation of an innovative training program promoting checklists in intensive c
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    Findings: Most of these risk controls – 35 out of 42 – would be classified as ‘administrative’ by the HoC, and thus considered weak. The risk controls that fell into this ‘administrative’ category included training, standardising processes and procedures, and changing the design and organisation of care. Since other evidence shows these approaches can sometimes be very successful in healthcare, it is probably a mistake to automatically assume they are weak. Completely eliminating reliance on human behaviour is very difficult in the healthcare context and would introduc
  13. Gallery Image
    Noradrenaline and tranexamic acid.jpg
    Shared with hub by Dr Abigail Clark-Morgan: Images shared of our stocked noradrenaline ampules and tranexamic acid – these have been mixed up and we are looking to stock alternative volumes of noradrenaline to reduce the likelihood of confusion. The incident also highlighted the importance of checking all the ampules drawn up, drawing up your own medications at the point of administration and effective second checking. Part of our immediate response was to label the noradrenaline ampules to make them more obviously different (the purple ampules pictured below).

    © Healthcare UK

  14. Event
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    This virtual seminar from the Clinical Human Factors Group will be looking at Just Culture and incident investigation and will feature two of the authors, Jan Davies and Carmella Steinke, of the new book 'Fatal Solution' , a book which describes "how a healthcare system used tragedy to transform itself and redefine Just Culture". In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put t
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    The book aims to provide well-founded, practical guidance to those responsible for leading and implementing human factors programmes and interventions in health and social care. Chapter 2 objectives and learning outcomes: To describe, in simple terms, the concept of organisational culture, and specifically how safety culture relates to this. To recognise features of good safety culture. To define key concepts of proactive risk management. To briefly introduce the idea of safety management systems and safety cases. To introduce methods for assessing safety c
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    They conclude there is sufficient reason to question the use of the Independent Double Check process. Following their findings they felt confident in returning to a single check process. Read the full paper via the link below.
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    Bupivacaine alongside sodium choloride.jpg
    Bupivacaine solution, a medication used to decrease feeling in a specific area, alongside sodium chloride used as a saline solution. What could go wrong?! Another example of almost identical packaging/labelling.
  22. News Article
    A French study of adverse drug reactions has a highlighted a link between drug shortages and medication error. Data from the French Pharmacovigilance Database show that medication errors were identified in 11% of the 462 cases mentioning a drug shortage. The researchers found that medication errors usually occurred at the administration step and involved a human factor. “A drug shortage may lead to a replacement of the unavailable product by an alternative,” the researchers wrote. “However, this alternative may have different packaging, labelling, dosage and sometimes a differen
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