If patient safety is to improve healthcare needs to change. The historical top down approach which has hindered improvement requires a transition into one where decisions are driven from the front line. Those corporations who’ve introduced front line driven frameworks (e.g. Toyota Production System – see here) provide the highest quality in the most efficient way to their customers. Transitioning to this approach will not happen overnight. … Continue reading 12. Bullying, Threats & Intimidation

Front line work environments are full of unnecessary distractions detracting focus from the task at hand.  They come in many forms from a noisy vacuum cleaner disrupting a patient consult, to a poorly designed electronic medical recording system. Dr Gordon Caldwell has presented much work specifically looking at how distraction increases misdiagnosis – see here: 1,2,3. He discusses how optimising work environments to minimise distractions … Continue reading 11. Distraction

It’s counter-intuitive that an alert designed to improve safety may actually be detrimental to patient care. Unfortunately alerts on their own may absolve governing bodies from ensuring more effective interventions. The diagram below (created by Cassie McDaniel) neatly demonstrates which interventions are most effective at improving safety. Forcing functions represent a solution which designs out an error, preventing the error from being made. Ideally a … Continue reading 10. Alerts & Other Less Effective Interventions

When an aeroplane crashes hundreds often die. This concentration of deaths lends the aviation industry tremendous energy in ensuring the same adverse event doesn’t happen again. Healthcare rarely benefits from the same fate. ‘Over the last few years NSW Health have received numerous reports of death and morbidity from central line related air emboli’. This statement in itself is a ‘call to action’. ‘Why don’t … Continue reading 9. Dispersion

Recently a tragic mix up where oxygen tubing was connected to a urinary catheter resulted in the death  of ex-Socceroo Steve Herczeg (see here). ‘How can anyone make this mistake?’ Unfortunately events like this occur regularly – we often only here of them via the media – our error report systems lacking transparency (see here). This link from the FDA (see here) documents numerous similar … Continue reading 8. Complexity

One major objective of a ‘Root Cause Analysis’ is to: ‘Look for improvements rather than apportion blame’ Recently, a tragic gas pipeline crossover resulted in death of a newborn, and left another with severe brain injury. Prior to this incident many clinicians believed pipeline errors had been relegated to history. Unfortunately pipeline crossovers occur with relentless frequency (see below) – the RCA team may not have appreciated … Continue reading 7. The Blame Game

‘When faced with a human error problem you may be tempted to ask ‘Why didn’t they watch out better? How could they not have noticed?’ You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. They are all expressions of the ‘Bad Apple Theory’ where you believe your … Continue reading 5. Bad Apple Theory

In doing nothing we have still made a decision. Bystander Effect: the greater the number of people present, the less likely people are to help. The bystander effect was first demonstrated following the murder of Kitty Genovese in 1964. The New York Times published a report conveying a scene of indifference from neighbors who failed to come to Genovese’s aid, claiming 38 witnesses saw or … Continue reading 4. The Bystander Effect

‘Senior doctors may actively oppose or denigrate methods which are safer and/or more successful — not just for themselves but for their learners and the system as a whole too — in part because the innovation makes their own deft skill with the old tools less important.’ – Dr Robert Farrell. ‘A disturbing (but very natural) ego-protective attitude occurs where staff reject innovations that make their carefully-honed … Continue reading 2. Ego

What is our great fear in medicine? Hurting people. Not being good enough. And when we change a process for the better it inevitably implies that our PREVIOUS way of doing things was (at least relatively) harmful. To make a minor change for the better, we might have to accept we have been hurting people, maybe killing people (or putting them at risk of death) … Continue reading 1. Cognitive Dissonance

3 year old dies from avoidable air embolus. Mind the Gap & Why ‘Ruby’s Rule’ Won’t Work Ruby Yen Chan, a 3 year old from Queensland, died from an air embolus. You can read the coroners report here. The process of disconnecting an intravenous fluid bag allowed air to enter it. When the bag was later re-connected (re-spiked) the air passed through the intravenous line … Continue reading 6. Mind the Gap

Patient safety suffers from a lack of transparency with our incident reporting systems. In healthcare front line staff can’t access valuable information in their error databases. This lack of transparency leaves us flying blind. Without seeing our errors we can’t improve. The repercussions of this are dreadful for patients, families and front line staff. Recently we came across a fantastic database –  SkyBrary (see here) … Continue reading 3. Lack of Transparency