The future of safety?
Archive for the ‘Patient Safety’ Category
The “smart room” by GE
In Human Factors, Patient Safety, Safety climate on September 16, 2010 at 7:46 pmMissed Care: an error of omission
In Interuptions, Multitasking, Patient Safety on September 16, 2010 at 7:21 pmAccording to Kalisch, Landstrom and Hinshaw (2009) one overlooked aspect in addressing patient safety is the concept of “missed care.” Missed care is classified in terms of error as an act of omission. Missed care is a concept that nurses are very well aware of but hesitant to bring into open discussion (Kalisch, et.al, 2009). Some reasons suspected for covering up these omissions are guilt, a feeling of powerlessness to correct the situation and fear of punishment for not completing tasks. There are even reports of false documentation to hide these errors of omission because of fear of retribution and an acceptance of this being the norm (Kalisch, et al, 2009). Kalisch, et al, (2009) liken this hiding of these errors to the hiding of medication errors and near misses that was prevalent prior to the patient safety movement…. more Read the rest of this entry »
Fun with Human Factors Part Two
In Patient Safety on September 11, 2010 at 5:26 pmTry this training exercise from the IHI Open School for Health Professionals:
Visit any of the following: •Restaurant •Coffee shop •Transportation system •Retail store •Hotel •Major intersection •Library •Health care setting
Take note – can you spot human factors issues that create opportunities for errors?
•What processes rely on memory?
•What tools can be used to eliminate the need to rely on memory?
•How well would the processes you observe work if the individual involved were tired? Distracted?
•What types of errors might occur? How would someone know if these error(s) had occurred?
•Are there steps that can be skipped or bypassed? Is this a good or bad design? Why?
•Would a new person be likely to make more, less or the same number of errors as an experienced person? Why?
•Are there systems in place ‐‐ or that should be in place – to minimize the opportunities for error?
If you have a chance to perform this exercise please share your observations in the comment section 🙂
BP blames rig explosion on series of failures
In High Reliability Orgs, Patient Safety on September 8, 2010 at 12:42 pmMore support for the swiss cheese theory of accident causation and normal accident theory:
“It is evident that a series of complex events, rather than a single mistake or failure, led to the tragedy,” said Tony Hayward, BP’s departing chief executive.
Read the story on USA Today.com
Read it: “Crisis Management in Acute Care Settings”
In Human Factors, Patient Safety on September 8, 2010 at 12:06 pmCrisis Management in Acute Care Settings by Pierre, Hofinger, and Buershaper (2008).
This is one of those books that I find so relevant I have read it several times and own the hardcover, the paperback and the Kindle version. I have referred to it numerous times in papers and conversations. It is a short book at 227 pages but every page is filled with amazing material.
The preface to the book begins with the quote “All of life is problem solving” (Popper). Since they say it better than I, here are excerpts from the authors’ words describing what this book is about:
On a regular basis, healthcare professionals are faced with problems that are sudden, unexpected and pose a threat to a patient’s life. Worse still, these problems do not leave much time for… Read the rest of this entry »
Human Factors and Ergonomic Studies
In Patient Safety on September 7, 2010 at 9:58 pmIn the future I am hoping to plan a research project involving human factors and ergonomics and nursing care delivery. One of the tools I hope to use is the device known as The Bodymedia Fit Armband. This device is worn 24 hours a day on one’s upper arm. It collects data
by using an accelerometer to count steps, skin temperature and galvanic skin response to measure body heat and activity, and heat flux to measure the heat your body gives off to the environment (Bodymedia, 2008)….Read more…
Read the rest of this entry »
Comments on a failure
In Patient Safety on September 6, 2010 at 9:45 pm
Link: The IHI collects thoughts on the issue of the error of wrong sided surgery.
Patient-Speak
In Patient Safety on September 6, 2010 at 3:59 pmHere is a blog developed to let patients speak about unsatisfactory experiences with the healthcare system. Their experiences are described as well as suggestions for improvement. Read through the stories to see if what they experienced could also happen in your environment.
Patient Safety Blog -Telling our Stories The purpose of the blog created in 2007 is ” … to teach and encourage patients and patient advocates to become knowledgeable, pro-active, and empowered partners with their doctors and nurses. The website provides unbiased advice to keep our parents, children and other loved ones with acute or chronic illnesses healthy and safe from medical errors (Farbstein, 2007).” The blog is run by Ken Farbstein.
Rapid Response, MEWS and PEWS
In Checklists, Patient Safety on September 6, 2010 at 3:40 pmMany Rapid Response teams have been formed in hospitals as a result of the IHI’s 5 million Lives campaign. Early warning system tools are also a recommendation along these lines to help identify when activate the Rapid Response Team. One hospital in Wales has developed MEWS* (Modified Early Warning System). The MEWS consists of a scoring tool and interventions based on these scores in assessing a deteriorating adult patient. View the MEWS. The tool is compact in that the scores in the middle show zero for normal then go out to the left as 1-2-3 for parameters that are dangerously low and out to the right as 1-2-3 for parameters that are dangerously high. Interventions for scores are listed at the bottom. This is a user friendly all-in-one algorithm/flowchart template for a safety assessment tool….. Read the rest of this entry »
Berwick, Pronovost and Wachter
In Patient Safety on September 4, 2010 at 6:10 pmA call for new safetydogs from Wachter’s blog:
“…I fear that it means that the business case to improve quality and safety has not yet reached the point where full engagement by healthcare organizations and caregivers isn’t dependent on the personal engagement of individuals with unique leadership and communication skills. We’ll know it has when states and CEOs are asking – even begging – Peter to help them prevent ICU infections, and when IHI and similar organizations are being tapped constantly for help, even if the answer to the predictable question, “Can Don come to our hospital to kick off our initiative?,” is always “no.”
We’re blessed to have the likes of Pronovost and Berwick in the quality and safety arena – we’d never have gotten to where we are today without them. But we’ll know that we have truly arrived when we no longer depend on them to get the work done.”
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