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.
Building on its successful predecessors, the third edition of The Field Guide to Understanding ‘Human Error’ will help you understand a new way of dealing with a perceived 'human error' problem in your organisation. It will help you trace how your organisation juggles inherent trade-offs between safety and other pressures and expectations, suggesting that you are not the custodian of an already safe system. It will encourage you to start looking more closely at the performance that others may still call 'human error', allowing you to discover how your people create safety through practice, at
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
About the authors
Robert W. Proctor is a distinguished professor of Psychological Sciences at Purdue University. He is a fellow of the American Psychological Association, Association for Psychological Science, and the Human Factors and Ergonomics Society, and recipient of the Franklin V. Taylor Award for Outstanding Contributions in the Field of Applied Experimental/Engineering Psychology from Division 21 of the American Psychological Association in 2013. He is co-author of Stimulus-Response Compatibility: Data, Theory and Application, Skill Acquisition & Training, and co-editor of Ha
The patient was a 62-year-old man who underwent hip replacement surgery. During his surgery, incompatible prostheses made by different manufacturers were used. The error was identified when data from the procedure was recorded in the National Joint Registry several days later.
The investigation centred on how the error occurred and what safety recommendations we could make to reduce the risk of a similar event happening again.
The investigation focuses on hip replacement surgery but the findings are applicable to all orthopaedic joint replacements.
The report documents concerns about the lack of a properly independent investigation system, unlike deaths in prison and police custody which are independently investigated pre-inquest, and the consistent failure by most NHS Trusts to ensure the meaningful involvement of families in investigations.
Ultimately, it highlights the lack of effective public scrutiny of deaths in mental health detention that frustrates the ability of NHS organisations to learn and make fundamental changes to policy and practice to protect mental health in-patients and prevent further fatalities and argues for u
How can nurses spot error traps and near misses so that Trusts can learn, respond and take action to prevent unsafe care? What are the barriers to nurses using their insight and where is the good practice that we can share? Any ideas, anyone?
All patients should be informed of the risks of general anaesthesia, including the possibility of AAGA, before their surgery.
When consenting patients, practitioners should use a form of words that proportionately conveys the risks of AAGA.
Consent for sedation should emphasise that the patient will be awake and therefore may have recall for at least parts of the procedure.
Practitioners should identify certain situations or certain patient factors as constituting a higher risk for AAGA (including organisational factors such as overbooked or reorgani
The report comes after the Healthcare Safety Investigation Branch (HSIB) looked at the case of 75-year old Ann Midson, who was left taking two powerful blood-thinning medications after a mix-up at her local hospital where she was receiving treatment whilst suffering from incurable cancer.
Ann sadly died from her cancer 18 days after being discharged and the error with her medication was only picked up three days before. This led to the HSIB investigation to question why this happened, even when the hospital had an ePMA system in place.
The report highlights that many NHS trusts acros
I started my career in a care of the elderly ward (geriatrics), which was exciting as my first job, and I felt that my time management needed to be worked on prior to me starting my career in what I knew at the time to be emergency nursing. I stayed in this area for a year, taking charge of the shift and also managing a bay of eight patients, which was the norm (or so I thought). After about 1 year, I thought about moving on, continuing to learn, and I started working in an intensive care unit (ICU).
During my time in ICU, I made a drug error involving a controlled drug. Without going in