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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.

Key recommendations 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 reorganised surgical lists) and highlight these at the WHO premeet/team brief. During induction of anaesthesia, practitioners should adhere to suitable dosing of intravenous agent, check anaesthetic effect before paralysis or instrumentation of the airway and maintain anaesthetic administration, including during transfer of patients (which is facilitated by a simple ABCDE checklist). If AAGA is suspected during maintenance (e.g., by patient movement), prompt attention should be paid to giving verbal reassurance to the patient, increasing analgesia, and deepening the level of anaesthesia. For cases requiring paralysis, the minimum dose of neuromuscular blocking drugs (NMBDs) that achieves sufficient neuromuscular blockade for surgery should be used, and the nerve stimulator is an essential monitor to titrate the dosing of NMBDs to this minimum. Where total intravenous anaesthesia (TIVA) is used, practitioners should adhere to the relevant recently published guidelines. At emergence, practitioners should first confirm that surgery is complete, then ensure NMBDs are adequately reversed before allowing the patient to regain consciousness. Practitioners should then manage the patient experience, particularly during awake extubation, by speaking to the patient. Cases of AAGA should be managed using the NAP5 pathway as a guide.

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 urgent change to policy and practice.

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 across England are taking up this technology as they reduce medication errors, but that incomplete use of e-systems could create further risks to patient safety. The investigation found that often all the functions of ePMA systems aren’t being used and that staff switch between using paper record and digital records, increasing the likelihood of crucial information being missed. Ann’s case also highlighted the routine lack of information sharing between NHS services, such as GP surgeries and pharmacies. She had been taking one blood-thinning medication on admission. This was stopped during her time at the hospital, but this message was not relayed to her local pharmacy and she continued to take both after leaving the hospital. The report also identifies that the availability of a seven-day hospital pharmacy service is crucial to support a digital system and pick up any errors quickly. The length of time it took in Ann’s case had a huge effect on both her and her family. Ann’s daughter said: “Not only were we grieving the loss of mum but also that she had to deal with the stress and upset of this towards the end of her life. She had to spend a lot of time within different parts of the NHS and all we ever wanted was for her to get the best possible care at every stage.

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 Handbook of Human Factors in Web Design. Trisha Van Zandt is a professor of Psychology at The Ohio State University. She is a member of the Society for Mathematical Psychology, of which she was President in 2006-2007, and the American Statistical Association. She has received multiple research grants from the National Science Foundation and the Presidential Early Career Award for Scientists and Engineers in 1997. She is co-author of review chapters "Designs for and Analyses of Response Time Experiments" in the Oxford Handbook of Quantitative Methods and "Mathematical Psychology" in the APA Handbook of Research Methods in Psychology.

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 all levels of your organisation, mostly successfully, under the pressure of resource constraints and multiple conflicting goals. The Field Guide to Understanding 'Human Error' will help you understand: how to move beyond 'human error' how to understand accidents how to do better investigations how to understand and improve your safety work. You will be invited to think creatively and differently about the safety issues you and your organisation face. In each, you will find possibilities for a new language, for different concepts, and for new leverage points to influence your own thinking and practice, as well as that of your colleagues and organisation.

and a pioneer in emerging risk.

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 into too much detail, there was a lot of factors involved in this case and I was told I was going down the disciplinary route. This was a real low point for me and I felt like I really needed support, not only to come to terms with the error itself, but also support from a reflective side – what I can do, so this doesn’t happen again. I was a new band 5 nurse in the department with no previous ITU experience, with a new Band 6 and Band 7 leading the team which we were working with solidly. They chose not to suspend me, but keep me working without being able to complete medications. I continued to work as per rota, never taking a day off sick, etc. This continued for about 3 months unable to complete my job role to its full potential, and continuing the days and nights and the weekend shifts, along with personal issues of my own to contend with also. I thought at the time it was normal to feel like this post an error, but in hindsight, the support I received was not adequate. In fact, I would go as far as to say I didn’t get any support, other than the normal "are you okay" at the start of each shift. By the time the disciplinary happened, I was 'rock bottom', which is banded around a lot, but I didn’t see a way out, without my family and partner saying that I needed to get out, I don’t know what I would have done. Nevertheless, I left for new horizons, and changed my speciality. I went to A&E where I knew I wanted to be, with a great team, with great management and culture. However, one day I let them down. I completed a second drug error. This was involving an insulin/dextrose infusion for hyperkalaemia, which I mixed up for hyperglycaemia. This error rattled me again. I felt like I was going down that 'rabbit hole' yet again, becoming more and more anxious and needing extra support, more than ever. Fortunately, the patient was okay and was identified quickly. The error was serious and after talking to my manager, they suspended me from clinical duties whilst the investigation was occurring. This was absolutely devastating to me. I felt like I was just settled in my job, feeling more positive about my career that I love so much. Whilst the investigation was going on, I continued my non-clinical work, completing various tasks that would normally take an age to complete. This is where I fell in love with the non-clinical side of the department and continue to work in this area today. However, in contrast to the first incident, I was asked whether I was okay, but also followed up with regular 1:1 welfare meetings, and felt like my manager was actively supporting me. I also started a piece of work on preventing this incident happening again. I have now gone up the ladder in the same organisation, and continue to feel settled. However, this really put the importance of supporting people as one of the main priorities in my daily practice. It also put into context the real need for establishing and integrating a no blame culture and getting rid of the culture of fear. It is very easy to forget the mental health aspect. Patient safety is aimed at patients (quite rightly so), but I think somewhere in the mix, we forget about that individual who takes this home day in, day out. I understand that there is accountability and there is taking responsibility for your actions as per the Nursing & Midwifery Council (NMC) Code of Conduct. But I think we forget about humanity and the need for support and coming together when one of your team is 'down'. I can honestly say, without my team and my managers, I wouldn’t be the nurse I am today, and I am forever grateful. And those people who have done errors or know what this is like, maybe you’re going through this today; there is light at the end of the tunnel. I share my story with the upmost respect and apologies to the patients involved and also to my team!

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.

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.

Podcast 1 – Interview with Chris Frerk Podcast 2 – Interview with Mark Stacey Podcast 3 – Interview with Stephen Hearns Podcast 4 – Interview with Claire Cox