Archive for the ‘safety’ Category

Organizational justice

In organizational justice, safety on March 27, 2015 at 5:26 pm

There some in organizational psychology who feel just culture isnt enough to promote a culture of safety. Where just culture deals with response to behavior directly related to safety, organizational justice refers to employees overall perception of fairness in the workplace. Safety culture may be more influenced by this as hypothesized by Weiner, et al (2008). It isnt known how different groups who work in the healthcare environment perceive justice in the workplace. IF doctors are treated differently than nurses does that impact safety culture? If one group has a better supervisor than another does that impact safety culture?

Weiner Hobgood and Lewis Highly recommended reading
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How do leaders factor into this? Walk the walk and talk the talk have never been more important. Check out this recent study about hypocritical leadership

Capitol Hill and Patient Harm

In safety, Safety climate on July 19, 2014 at 8:26 am


WASHINGTON, D.C. — The health care community is not doing enough to track and prevent widespread harm to patients, and preventable deaths and injuries in hospitals and other settings will continue unless Congress takes action, medical experts said today on Capitol Hill.

“Our collective action in patient safety pales in comparison to the magnitude of the problem,” said Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine. “We need to say that harm is preventable and not tolerable.”

Dr. Ashish Jha, a professor at the Harvard School of Public Health, said patients are no better protected now than they were 15 years ago, when a landmark Institute of Medicine report set off alarms about deaths due to medical errors and prompted calls for reform.

“We can’t continue to have unsafe medical care be a regular part of the way we do business in health care,” Jha said.
read the full article

The gold standard may be tarnished…

In Neuroscience, safety on October 20, 2013 at 1:38 pm

disturbing news on research replicability in The Economist
Many study results cannot be replicated

Stamp out unsafe processes

In Root cause analysis, safety on September 20, 2013 at 8:18 am

From Nancy Leveson’s site at MIT

Applying System Engineering to Pharmaceutical Safety by Nancy Leveson, Matthieu Couturier, John Thomas, Meghan Dierks, David Wierz, Bruce Psaty, Stan Finkelstein. Journal of Healthcare Engineering, Sept. 2012.

While engineering techniques are used in the development of medical devices and have been applied to individual healthcare processes, such as the use of checklists in surgery and ICUs, the application of system engineering techniques to larger healthcare systems is less common. System safety is the part of system engineering that uses modeling and analysis to identify hazards and to design the system to eliminate or control them. In this paper, we demonstrate how to apply a new, safety engineering static and dynamic modeling and analysis approach to healthcare systems. Pharmaceutical safety is used as the example in the paper, but the same approach is potentially applicable to other complex healthcare systems.
One use for such modeling and analysis is to provide a rigorous way to evaluate the efficacy of potential policy changes as a whole. Less than effective changes may be made when they are created piecemeal to fix a current set of adverse events. Existing pressures and influences, not changed by the new procedures, can defeat the intent of the changes by leading to unintended and counterbalancing actions by system stakeholders. System engineering techniques can be used in re-engineering the system as a whole to achieve the system goals, including both enhancing the safety of current drugs while, at the same time, encouraging the development of new drugs.

Read this an other papers about this new model of incident investigation here

Culture Pathogens

In culture, safety on December 23, 2011 at 9:23 am

It is ironic that in healthcare cultures refer to the test that helps us identify pathogens that allow us to save lives and also to the environment in which we practice which can also help us save lives.

In a previous post, I presented the link to AHRQs latest Hospital SOPS (Survey of Patient Safety culture). Of particular concern were the safety culture perceptions of nurses in the northeast USA.
This latest article involves nurses in the Northeast UK.
“MORE than one in four nurses in the North-east have been discouraged from raising concerns about patient safety, according to a survey.
Nurses from across the North-east and Cumbria voiced their fears about reporting concerns over the quality of patient care as some of the 3,000 members of the Royal College of Nursing (RCN) nationwide who were surveyed. The research, involving private healthcare and NHS workers, highlighted a worrying number who said they had been told by their managers not to report their concerns. A significant number also said that when they reported their concerns over patient safety and quality of care issues, no action was taken by management.
Read More

How powerful is hospital culture? So powerful it overrides racial and national culture as nurses in the UK and the USA are having the same perceptions around the existing culture of safety.

Safety Mantra: Can’t not Don’t

In Patient Safety, safety on December 18, 2011 at 2:24 pm

“Don’t do this..”  has never worked for safety in any industry. For example, in manufacturing, a machine called the punch press took many fingers of workers who were not responsive to warning notices and red lights etc.  Safety was not achieved until the punch press was redesigned such that TWO hands were required on the buttons to start the action of the machine.  Making sure the hands were being used to run the machine prevented hands from being inadvertently left inside the machine (Levinson, 2011).  This is an example of CANT  not DONT.

Safety is achieved by force function eg.  can’t do it any other way but the right way.  Worker vigilance is not reliable or sustainable.  Some other examples of CANT not DONT include the SPIKERIGHT enteral system from Nestle which prevents a tube feeding from being connected to IV access.  more—- Read the rest of this entry »

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 »

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.


Read the rest of this entry »

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