To begin the interview, we discussed the events leading up to Keith joining HSIB as its first Chief Investigator. He spoke about his background as a pilot and then joining the Air Accidents Investigation Branch, first as an investigator before later becoming its Chief Investigator. There has been much written about the safety lessons that healthcare can learn from the aviation industry. Keith reflected on how his investigation roles in aviation helped to develop his understanding of the importance of creating a safety culture and the role of investigations as part of this.
1 Error trap gallery - medication
the hub’s error trap gallery provides a place to share examples of error traps you come across in your day to day work, including error traps relating to medications. An error trap is a situation that could lead to avoidable harm if not mitigated. It is a situation where the circumstances work alongside human limitations to make errors more likely—for example, packaging design that makes it hard to distinguish one medication from another. Medications with similar packaging are one of the most common error traps in busy hospitals, and being aware of them c
Summary of recommendations
The following recommendations are made to support the delivery of a new regional policy/procedure for reporting, investigating and learning from adverse events.
The Department of Health should work collaboratively with patient and carer representatives, senior representatives of Trusts, the Strategic Performance and Planning Group, Public Health Agency and Regulation and Quality Improvement Authority to co-design a new regional procedure based on the concept of critical success factors. Central to this must be a focus on the involvement of patients and f
The authors identified a range of internal and external barriers to UDI implementation in health systems, including:
lack of organizational support
information technology gaps
information technology vendor resistance
limitations in manufacturer support
gaps in reference data
lack of an overall UDI system).
They also identified strategies for overcoming these barriers, including:
They concluded that next steps to advance UDI adoption nee