SafetyDog

Archive for the ‘Patient Safety’ Category

Usability and Safety

In ergonomics, Human Factors, Patient Safety, Resiliency, safety on November 24, 2010 at 2:13 pm

* please watch video at the end of this post*
In reading articles and other literature on safety one will find recommendations based on their strength of effectiveness.
Here is a chart from an article by Stevens, Urmson, Campbell and Damignani (2010):

How it works: A simple safety intervention in a hospital is to have everyone wearing visible picture IDs. Problem: the IDs keep flipping over hiding the face and name of the employee. Solutions from least effective to most effective:

  • put a warning on the non-picture side that says “this side faces in” (safety still depends on human action)
  • train the employees to remember to periodically check to ensure their badge is facing out (safety depends on human memory)
  • put the picture on BOTH sides of the badge so the flipping over does not compromise the safety system (safety achieved from designing forced function!)

We tend to rely too much on training and memory: read more Read the rest of this entry »

Creative Patient Safety from Metro West!

In Patient Safety on November 17, 2010 at 11:13 am

A short list of Don’ts

In human error, Human Factors, Patient Safety on November 7, 2010 at 8:09 pm

When the outcome of a process is known, humans can develop a bias when looking at the process itself. When anesthesiologists were shown a sequence of the same events, being told there was a bad outcome influenced their evaluation of the behavior they saw (Woods, Dekker, Cook, Johannesen & Sarter, 2010). This has shown to be true in other professions also. This tendency to see an outcome as more likely than it seemed in real time is known as hindsight bias. This is why many failures are attributed to “human error.” In actuality, the fact that many of these failures do not occur on a regular basis show that despite complexity, the humans are somehow usually controlling for failure. It is important to study the failure as well as the usual process that prevents failure.

When following up on a failure in a healthcare system, Woods, et al., (2010) recommend avoiding these simplistic but common reactions:
“Blame and train”
“A little more technology will fix it”
“Follow the rules”

Human Error in the news

In Patient Safety on November 6, 2010 at 1:23 pm

Read the following from Google News this week. These are all being called “human error” although many seem like they are predictable human factor issues that should be built into safety systems. These involve police, pilots and NASA.

Police:
A woman reported calling 911 three times after being punched in the face by her brother. The call was sent to two different country police offers who were dealing with another violent situation nearby and an Alzheimer’s woman who was missing. The call center logged the complaint by woman who was punched, but the officers did not follow through with procedures. click read more below Read the rest of this entry »

Best Practice Alarm Fatigue

In alarm fatigue, Patient Safety on November 5, 2010 at 11:54 am

I thought I would share references from a recent literature search on alarm fatigue and cardiorespiratory monitoring of patients.

References
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Man versus System

In human error, Normal Accident Theory, Patient Safety, Safety climate on November 5, 2010 at 10:20 am


The person approach to looking at safety issues assumes failures are the result of the individual(s) involved in direct patient contact.  In this model, when something goes wrong it is the provider’s fault due to a knowledge deficit, not paying attention (and other cognitive processes), or not at their best (St. Pierre, et al., 2008).  Some other descriptions assumed of  individuals involved in a person approach to failures include: forgetful, unmotivated, negligence, lazy, stupid, reckless…click below to read more Read the rest of this entry »

Poll

In Patient Safety on November 5, 2010 at 9:23 am

In a just and high safety culture, failures are looked at in a systems approach rather than via the blame the individual approach. In a resilient organization that is consistently monitoring its failures and potential for failures, the most likely statement would be: There was a medication error in the PACU. The processes that led to the failure would be reviewed and a prevention plan would be developed with the assistance of the nurse who was at the sharp end of the failure.
The statement about the 5 rights is not likely to be heard as this also implies only individual accountability. For more information about weaknesses in reliance on the 5 rights framework, read this from the ISMP:

Q: Won’t medication errors be prevented if nurses just follow the “Five Rights?”
A: Many nurses during their training have learned about the “five rights” of medication use: the right patient, drug, time, dose and route.

However, the “five rights” focus on the nurse’s individual performance and does not reflect that responsibility for safe medication use lies with multiple individuals. Although the “five rights” serve as a useful check before administering medications, there are many other contributing factors to a staff member’s failure to accurately verify the “five rights,” despite their best efforts. For more detailed information, see the following articles.

•“Nurses’ rights regarding safe medication administration” ISMP Medication Safety Alert!® Nurse Advise-ERR July 2007
•The five rights: A destination without a map ISMP Medication Safety Alert!® Jan. 25, 2007
•“The five rights cannot stand alone” ISMP Medication Safety Alert!® Nurse Advise-ERR November 2004
•The “five rights” ISMP Medication Safety Alert!® April 7, 1999
ISMP report.

Conflict of interest?

In Patient Safety on November 5, 2010 at 8:04 am

This is an interesting twist on safety efforts. In a described patient safety effort, The Joint Commission is sponsoring a contest for employee vaccination percentages. The final line is this: Funding and other editorial support for the Flu Vaccination Challenge has been provided by GlaxoSmithKline.

http://www.jcrinc.com/Blog/2010/10/26/Over-1-100-Health-Care-Organizations-Have-Joined-the-Flu-Vaccination-Challenge/

Should a vaccination contest be funded by :the makers of vaccines?

http://www.gsk.com/products/vaccines/index.htm

This highlights a potential determent to patient safety. We need to continually focus on evidence based information and scholarly information and not information that is really just cleverly disguised advertising.

Dead by Mistake

In High Reliability Orgs, hospital, Patient Safety, safety, Safety climate on October 29, 2010 at 8:03 pm

Healthcare providers know that the public is invested in the reporting of and the prevention of medical errors. The website Dead by Mistake is run by Hearst newspapers and is a consumer oriented site with scary stories of medical mishaps that would make even the bravest among us afraid to receive hospital care.

More

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Team Up! with Patients!

In Patient Safety on October 28, 2010 at 8:46 pm

View the brochure for Team Up :

This is geared to the patient and designed to engage them in a shared mental model to enhance hospital safety.  It helps staff and patients get on the same page in terms of their plan of care. Click image.

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