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Found 275 results
  1. Content Article
    This paper reviews the key perspectives on human error and analyses the core theories and methods developed and applied over the last 60 years. These theories and methods have sought to improve our understanding of what human error is, and how and why it occurs, to facilitate the prediction of errors and use these insights to support safer work and societal systems. Yet, while this area of Ergonomics and Human Factors (EHF) has been influential and long-standing, the benefits of the ‘human error approach’ to understanding accidents and optimising system performance have been questioned. This state of science review analyses the construct of human error within EHF. It then discusses the key conceptual difficulties the construct faces in an era of systems EHF. Finally, a way forward is proposed to prompt further discussion within the EHF community.
  2. Content Article
    A family describe the lengthy efforts they had to take to try to ensure their complaints about their loved one's end of life care would result in improvements at the hospital.
  3. Content Article
    A subjective, biased, and an open ended inquiry into one of the most famous accidents in the maritime history – the capsizing of the Costa Concordia.  Nippin Anand's first-hand interviews with the captain followed by a series of workshops around the world gradually became a source of learning and inner change. Read a foreword by Steven Shorrock Buy the book here
  4. Content Article
    Clinical guidelines can contribute to medication errors but there is no overall understanding of how and where these occur. This study aimed to identify guideline-related medication errors reported via a national incident reporting system, and describe types of error, stages of medication use, guidelines, drugs, specialties and clinical locations most commonly associated with such errors.
  5. Content Article
    Harm due to medicines and therapeutic options accounts for nearly 50% of preventable harm in medical care. This World Health Organization (WHO) policy brief is a resource for policy-makers, health workers, healthcare leaders, academic institutions and other relevant institutions to help understand the global burden of medication errors, address and prevent medication-related harm at all levels of healthcare, aligned with the strategic plan of the third WHO Global Patient Safety Challenge: Medication Without Harm. 
  6. Content Article
    Medication errors in ambulatory care settings present unique patient safety challenges. This systematic review explored the prevalence of medication errors in outpatient and ambulatory care settings. Findings indicate that prescribing errors (e.g., dosing errors) are the most common type of medication error and are often attributed to latent factors, such as knowledge gaps.
  7. Content Article
    Over the past decade, the implementation of simulation education in health care has increased exponentially. Simulation-based education allows learners to practice patient care in a controlled, psychologically safe environment without the risk of harming a patient. Facilitators may identify medical errors during instruction, aiding in developing targeted education programs leading to improved patient safety. However, medical errors that occur during simulated health care may not be reported broadly in the simulation literature. This study in the Journal of Patient Safety aimed to identify and categorise the type and frequency of reported medical errors in healthcare simulation.
  8. Content Article
    Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. In the article 'Truth and compassion' (page 20-21), David Alderson considers the patient’s perspective on mistakes.
  9. Content Article
    Children are more than twice as likely as adults to experience a medication error at home. In this interview for the journal Patient Safety, Dr Kathleen Walsh, paediatrician at Boston Children’s Hospital, discusses why that is the case and provides some tips to keep children—and adults—safe.
  10. Content Article
    SHOT is the UK’s independent, professionally-led haemovigilance scheme. It collects and analyses anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the United Kingdom. This document contains updated information on reporting categories and what to report to the scheme.
  11. Content Article
    Traditionally, recommendations regarding responding to medical errors focused mostly on whether to disclose mistakes to patients. Over time, empirical research, ethical analyses and stakeholder engagement began to inform expectations — which are now embodied in communication and resolution programmes (CRPs) — for how healthcare professionals and organisations should respond not just to errors but any time patients have been harmed by medical care (adverse events). CRPs require several steps: quickly detecting adverse events, communicating openly and empathetically with patients and families about the event, apologising and taking responsibility for errors, analysing events and redesigning processes to prevent recurrences, supporting patients and clinicians, and proactively working with patients toward reconciliation. In this modern ethical paradigm, any time harm occurs, clinicians and health care organisations are accountable for minimising suffering and promoting learning. However, implementing this ethical paradigm is challenging, especially when the harm was due to an error.
  12. Content Article
    Interprofessional communication is of extraordinary importance for patient safety. To improve interprofessional communication, joint training of the different healthcare professions is required in order to achieve the goal of effective teamwork and interprofessional care. The aim of this pilot study from Heier et al. published in BMC Medical Education was to develop and evaluate a joint training concept for nursing trainees and medical students in Germany to improve medication error communication.
  13. Content Article
    The US Food and Drug Administration (FDA) list of drug names with recommended tall man (mixed case) letters was initiated in 2001 with the agency’s Name Differentiation Project. Tall man lettering (TML) is a technique that uses uppercase lettering to help differentiate look-alike drug names. Starting on the left side of a drug name, TML highlights the differences between similar drug names by capitalizing dissimilar letters (e.g., vinBLAStine versus vinCRIStine and CISplatin versus CARBOplatin). TML can be used along with colour or bolding to draw attention to the dissimilarities between look-alike drug names, and alert healthcare providers that the drug name can be confused with another drug name. The Institute for Safe Medication Practices (ISMP) 'Look-alike drug names with recommended tall man (mixed case) letters' contains drug name pairs or larger groupings with recommended, bolded uppercase letters to help draw attention to the dissimilarities in look-alike drug names. The list includes mostly generic-generic drug names, although a few brand-brand or brand-generic names are included.  See also our Medication error traps gallery
  14. Content Article
    The relationship between management and the workforce, in very simplistic terms, can be considered one of reward in return for effort. The contracted effort is communicated through a roster. In organisations that have a continuous operation, blocks of effort are distributed to maintain the flow of output. The organisation of effort, then, is a legitimate function of management.  Norman's previous blog looked at performance variability under normal conditions. In this blog, Norman looks at the impact of physiological states and how management’s organisation of effort degrades decision-making.
  15. Content Article
    The healthcare workplace is a high-stress environment. All stakeholders, including patients and providers, display evidence of that stress. High stress has several effects. Even acutely, stress can negatively affect cognitive function, worsening diagnostic acumen, decision-making, and problem-solving. It decreases helpfulness. As stress increases, it can progress to burnout and more severe mental health consequences, including depression and suicide. One of the consequences (and causes) of stress is incivility. Both patients and staff can manifest these unkind behaviours, which in turn have been shown to cause medical errors. The human cost of errors is enormous, reflected in thousands of lives impacted every year. The economic cost is also enormous, costing at least several billion dollars annually. The warrant for promoting kindness, therefore, is enormous. Kindness creates positive interpersonal connections, which, in turn, buffers stress and fosters resilience. Kindness, therefore, is not just a nice thing to do: it is critically important in the workplace. Ways to promote kindness, including leadership modelling positive behaviours as well as the deterrence of negative behaviours, are essential. A new approach using kindness media is described. It uplifts patients and staff, decreases irritation and stress, and increases happiness, calmness, and feeling connected to others.
  16. Content Article
    In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk.  In part 1 of this blog series, Norman suggested that measuring safety is problematic because the inherent variability in any system is largely invisible. Unfortunately, what we call safety is largely a function of the risks arising from that variability. In this blog, Norman explores how error might offer a pointer to where we might look. 
  17. Content Article
    In this article, Stephen Shorrock, Chartered Ergonomist and human factors specialist, shares some some insights on the concept of ‘human error and the idea of ‘honest mistakes’. He outlines the problem with thinking of errors as ‘causing’ unwanted events such as accidents, arguing that this approach ignores all of the other relevant ‘causes’, especially in high-hazard, safety-critical systems,
  18. Content Article
    Stephen Shorrock looks at how we use deficit-based taxonomies when describing incidents in healthcare and why neutralised taxonomies may be more flexible and useful.
  19. News Article
    RaDonda Vaught was sentenced to three years of supervised probation on the 13 May for a fatal medication error she made in 2017 while working as a nurse at the Vanderbilt University Medical Center in the USA. In remarks made during the sentencing hearing, Ms. Vaught expressed concerns over what her case means for clinicians and patient safety reporting. "This sentencing is bound to have an effect on how [nurses] proceed both in reporting medical errors, medication errors, raising concerns if they see something they feel needs to be brought to someone's attention," she said. "I worry this is going to have a deep impact on patient safety." Numerous medical organisations expressed similar concerns in statements circulated after Ms. Vaught's sentencing. "To achieve our goal of zero patient harm and death from preventable medical errors, we need to foster a culture where leadership of hospitals and healthcare organizations support healthcare workers and encourage them to share near misses," the Patient Safety Movement Foundation said in a statement. "Healthcare workers are human and healthcare systems need to ensure there are appropriate processes in place to provide their staff with a safe and reliable working environment so they can provide their patients with the best care. Only by identifying potential problems and learning from them can change occur." Read full story Source: Becker's Hospital Review, 16 May 2022
  20. News Article
    On 25 March2022, a Tennessee jury convicted RaDonda Vaught, a nurse at Vanderbilt University Medical Center, of criminally negligent homicide and impaired adult abuse in a 2017 medication administration error that tragically resulted in a patient death. The Washington State Nurses Association have issued a joint statement adamantly opposed to criminalization of patient care errors. "Focusing on blame and punishment solves nothing. It can only discourage reporting and drive errors underground. It not only undermines patient safety; it fosters an environment of fear and lack of respect for health care workers." "The Vaught case has drawn intense national attention and concern. We join with health care workers and patient safety experts around the country and the world in rejecting the criminalization of medical errors. Further, we are committed to redoubling our efforts to achieve health care environments that are safe for patients and health care workers alike. This includes the ongoing, critical fight to achieve safe staffing standards in Washington state." Read full statement Source: Washington State Nurses Association, 8 April 2022
  21. News Article
    Emma Moore felt cornered. At a community health clinic in Portland, Oregon, USA, the 29-year-old nurse practitioner said she felt overwhelmed and undertrained. Coronavirus patients flooded the clinic for two years, and Moore struggled to keep up. Then the stakes became clear. On 25 March, about 2,400 miles away in a Tennessee courtroom, former nurse RaDonda Vaught was convicted of two felonies and facing eight years in prison for a fatal medication mistake. Like many nurses, Moore wondered if that could be her. She'd made medication errors before, although none so grievous. But what about the next one? In the pressure cooker of pandemic-era health care, another mistake felt inevitable. Four days after Vaught's verdict, Moore quit. She said Vaught's verdict contributed to her decision. "It's not worth the possibility or the likelihood that this will happen," Moore said, "if I'm in a situation where I'm set up to fail." In the wake of Vaught's trial ― an extremely rare case of a health care worker being criminally prosecuted for a medical error ― nurses and nursing organizations have condemned the verdict through tens of thousands of social media posts, shares, comments, and videos. They warn that the fallout will ripple through their profession, demoralizing and depleting the ranks of nurses already stretched thin by the pandemic. Ultimately, they say, it will worsen health care for all. Read full story Source: Kaiser Health News, 5 April 2022
  22. News Article
    Patient safety and nursing groups around the country are lamenting the guilty verdict in the trial of a former nurse in Tennessee, USA. The moment nurse RaDonda Vaught realised she had given a patient the wrong medication, she rushed to the doctors working to revive 75-year-old Charlene Murphey and told them what she had done. Within hours, she made a full report of her mistake to the Vanderbilt University Medical Center. Murphey died the next day, on 27 December 2017. On Friday, a jury found Vaught guilty of criminally negligent homicide and gross neglect. That verdict — and the fact that Vaught was charged at all — worries patient safety and nursing groups that have worked for years to move hospital culture away from cover-ups, blame and punishment, and toward the honest reporting of mistakes. The move to a “Just Culture" seeks to improve safety by analyzing human errors and making systemic changes to prevent their recurrence. And that can't happen if providers think they could go to prison, they say. “The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent,” the American Nurses Association said. “Health care delivery is highly complex. It is inevitable that mistakes will happen. ... It is completely unrealistic to think otherwise.” Read full story Source: The Independent, 31 March 2022
  23. News Article
    RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide on Friday after a three-day trial in Nashville, Tenn., that gripped nurses across the country. Vaught faces three to six years in prison for neglect and one to two years for negligent homicide as a defendant with no prior convictions, according to sentencing guidelines provided by the Nashville district attorney's office. Vaught is scheduled to be sentenced 13, and her sentences are likely to run concurrently, said the district attorney's spokesperson, Steve Hayslip. Vaught was acquitted of reckless homicide. Criminally negligent homicide was a lesser charge included under reckless homicide. Vaught's trial has been closely watched by nurses and medical professionals across the U.S., many of whom worry it could set a precedent of criminalising medical mistakes. Medical errors are generally handled by professional licensing boards or civil courts, and criminal prosecutions like Vaught's case are exceedingly rare. Read full story Source: OPB, 26 March 2022 See also: As a nurse in the US faces prison for a deadly error, her colleagues worry: Could I be next?
  24. News Article
    Doctors missed a man’s stroke which led him to suffer another one and go temporarily blind. The man said that the experience had changed him from ‘an outgoing social person, to a sheltered man living in fear that he is not being looked after competently’. The 75-year-old visited his GP in Darlington complaining of dizziness, light-headedness, and a numb foot. He had experienced a stroke and should have been immediately sent to hospital. But doctors missed the signs, diagnosed him with a ‘dropped foot’ and requested an urgent MRI scan. However, due to an administrative error the referral wasn’t made and the scan never happened. A month after visiting the GP, the man suffered a blinding headache and diminished vision. He saw an ophthalmologist who referred him to a specialist team. He had suffered another stroke. He also paid for a private scan which confirmed the first stroke happened a month earlier. Distressingly, the man lost vision in his right eye, which he was told could be permanent. Fortunately, his sight returned eight weeks later. His daughter, who described the experience as ‘horrendous’, complained to the Parliamentary and Health Service Ombudsman (PHSO) about her father’s care. The PHSO found that the initial symptoms were signs of a problem with nerve, spinal cord, or brain function. Doctors should have suspected a stroke and immediately sent him to hospital. If that had happened, the second stroke and sight loss would likely have been avoided. Ombudsman Rob Behrens said: “Having a stroke and then being told you could be permanently blind must have been incredibly frightening. The impact on the man, and his family who supported him through the ordeal, will have been deep and long-lasting. “Mistakes like these need to be recognised and acted upon so that they are not repeated.” Read full press release Read case file Source: PHSO, 4 October 2023
  25. News Article
    Sharri Shaw walked out of the CVS on Vermont Avenue in South Los Angeles in 2019 believing she had a prescription for the pain reliever acetaminophen. Instead the bottle held a medicine to treat high blood pressure, a problem she did not have. Shaw began taking the pills, not learning of the mistake until six days later when a CVS employee arrived at her home, according to a lawsuit she filed last year. The employee told her not to take the tablets, the lawsuit said, before leaving the correct prescription at her door. The mistake, she said, left her stunned. Shaw’s experience is far from an isolated event. California pharmacies make an estimated 5 million errors every year, according to the state’s Board of Pharmacy. Officials at the regulatory board say they can only estimate the number of errors because pharmacies are not required to report them. Most of the mistakes that California officials have discovered, according to citations issued by the board and reviewed by The Times, occurred at chain pharmacies such as CVS and Walgreens, where a pharmacist may fill hundreds of prescriptions during a shift, while juggling other tasks such as giving vaccinations, calling doctors’ offices to confirm prescriptions and working the drive-through. Christopher Adkins, a pharmacist who worked at CVS, and then at Vons pharmacies until March, said that management policies at the big chains have resulted in understaffed stores and overworked staff. “At this point it’s completely unsafe,” he said. Read full story Source: Los Angeles Times, 5 September 2023
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