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Team of Teams

Last year the BMJ reported medical error as the third greatest cause of death in healthcare. Does the design of error reporting systems render them powerless to change this? Current systems are designed using a command structure: Command structures have been present for hundreds of years and were used with great effect to improve efficiency during the industrial era. However they only work when those … Continue reading Team of Teams

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Time To Pull The Andon Cord

One day, some time in the future, a nurse or doctor will notice something – a piece of equipment, the way a drug is packaged, a problem with a system – and she will (metaphorically) pull a cord to sound an alarm. The siren that sounds will be a pleasant one and the issue will be made transparent. Staff will congratulate her and delight in … Continue reading Time To Pull The Andon Cord

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1. Paradigm Shift

What you see depends on what you’re conditioned to see. We’ve grown up in healthcare seeing education, policy writing and checklists as the most powerful tools for improvement. Those in the most influential positions are often academically gifted and tend to reinforce this behaviour. Education has served them proud, it has enabled them to excel. They may believe if others are as well educated many … Continue reading 1. Paradigm Shift

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12. Bullying, Threats & Intimidation

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

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11. Distraction

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

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10. Alerts & Other Less Effective Interventions

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

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Obstacles to Patient Safety

Everyone who belongs in healthcare passionately wants the best for patients. Medical error, however, persists as the third greatest cause of death. We have tremendous opportunity to improve. So what are the obstacles to patient safety? Despite appearing simple, removing unnecessary hazards within healthcare frameworks is extremely difficult. This ongoing series of posts uses specific hazards to demonstrate the obstacles to patient safety. We’ll persist … Continue reading Obstacles to Patient Safety

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Central Line Air Emboli: one death every day?

Central lines are essential for the care of many patients. Unfortunately worldwide data indicate around one patient is dying every day from avoidable central line related air emboli. We would appreciate your feedback on the numerous case series and reports presented below. These are more than just statistics. (Image above from CNN report) Sufficient air can enter blood vessels rapidly, over 1 or 2 seconds, … Continue reading Central Line Air Emboli: one death every day?

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9. Dispersion

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

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8. Complexity

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

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7. The Blame Game

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

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5. Bad Apple Theory

‘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

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4. The Bystander Effect

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

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2. Ego

‘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

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1. Cognitive Dissonance

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

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6. Mind the Gap

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

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What’s in the pipeline? Will we learn?

When adverse events occur our first instinct is to discover who or what is to blame. Staff may be remonstrated and potentially removed, in itself warning others not to make similar mistakes. Governing authorities may review related policies to prevent such errors in the future. This has been the response to the Bankstown gas pipeline tragedy (see here). Taken in isolation the recommendations made through the … Continue reading What’s in the pipeline? Will we learn?

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3. Lack of Transparency

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

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Why can’t staff just be more careful?

This sign may represent current health care safety strategy: ‘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 … Continue reading Why can’t staff just be more careful?

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Could an un-opened box have saved Elaine Bromiley?

We would all be more likely to administer a poison if the antidote were immediately available. After watching this video it’s obvious there’s numerous factors at play. One may conclude this has nothing to do with Sugammadex – rocuronium was never administered – this is the point for discussion. (40seconds post propofol administration – unable to insert LMA) To state Sugammadex could have saved Elaine … Continue reading Could an un-opened box have saved Elaine Bromiley?

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The Healthcare Safety Machine Needs Fixing

The healthcare safety machine needs fixing. Is there anyone out there who can help? Medical errors are the third greatest cause of death in hospitals. We know this. ‘The real problem isn’t how to stop bad doctors from harming, even killing, their patients. It’s how to prevent good doctors from doing so.’ Atul Gawande Terry Fairbanks is an expert on system safety. Watch his video here. … Continue reading The Healthcare Safety Machine Needs Fixing

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Approach Patient Safety Together & We All Win

Medical errors are the third greatest cause of death in hospitals. We know this. ‘The real problem isn’t how to stop bad doctors from harming, even killing, their patients. It’s how to prevent good doctors from doing so.’ Atul Gawande Terry Fairbanks is an expert on system safety. Watch his video here. He explains that, instead of focussing on people, we should focus on the hazards … Continue reading Approach Patient Safety Together & We All Win

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Hazard Feedback Framework

There is value in the prospective review of hazards. An approach to improve healthcare safety is to review hazards and assess proposed solutions using the framework presented below. This process could complement established incident reporting systems. Hazard – There is value in the prospective review of hazards over the retrospective assessment of incidents and near misses. Staff may be more willing to present hazards knowing … Continue reading Hazard Feedback Framework

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Patient Safety – Burn or Learn

Recently a friend showed me a lesion on her face she’d noticed after having dental work. Immediately I thought of facial burns from dental drills. I was first made aware of this issue by a  colleague who was acting as an expert witness in a case. Focus had been put on the dentists poor technique and the dental nurses failure to ensure the drills had … Continue reading Patient Safety – Burn or Learn

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User Centred Design

As you sign off on the electronic medication chart you fail to realise that you are still logged in to the previous patient. Unfortunately the previous patient now ends up having an apnoeic arrest and dies from an opioid overdose. On reflection you can’t help thinking that you would never made this mistake if the hospital was still using the old paper based system… I … Continue reading User Centred Design

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Drug Errors

‘1 in every 20 medications administered involved a drug error’ see Perioperative Medication Errors – Building Safer Systems The September issue of the ANZCA Bulletin had an article discussing the risk of having different drugs in very similar ampoules. Please see the EZDrugID website We aim to generate a list of the drugs contained in similar ampoules, suitable alternatives and their suppliers.  Please let us know … Continue reading Drug Errors

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Video & Direct Laryngoscopes

Devices allowing simultaneous video and direct laryngoscopy represent a safety advantage over either direct laryngoscopes or video laryngoscopes. Intubation is more likely to be successful, with less airway trauma. Video&direct laryngoscopes which are smaller and easily portable provide an advantage over those that aren’t. The McGrathMAC and C Mac portable possess these ideal properties. The first attempt at intubation should be the best (and ideally … Continue reading Video & Direct Laryngoscopes

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Warming Blankets

There have been concerns raised over the following warning and request on the packaging of this product. The request appears beyond what would be considered usual practice. Molnlycke are addressing this issue. See: Letter from Molnlycke 4th March 2016. Active self-warming blankets have several safety advantages over forced-air warmers. They may also represent a significant cost saving measure – linen usage will be greatly reduced. … Continue reading Warming Blankets

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Paradigm Shift

What you see depends on what your told to see. We’ve grown up in healthcare seeing education, policy writing and checklists as the most powerful tools for improvement. Those in the most influential positions are often academically gifted and tend to reinforce this behaviour. Education has served them proud, it has enabled them to excel. They may believe if others are as well educated many … Continue reading Paradigm Shift

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Hospital Gas Pipeline Mix Up Causes More Deaths

More deaths have occurred because of accidental hospital gas pipeline cross-overs. (To read about cases see here).   In Australia, 2016 was marred with the events which occurred at Bankstown Hospital (see here). NSW Health should be commended on the publication of their recommendations following the tragedy. It is useful to identify those involved, the procedures used and assess why errors were made. However consider for … Continue reading Hospital Gas Pipeline Mix Up Causes More Deaths

Indistinct chlorhexidine (centre of image) has been mistaken for other colourless solutions leading to patient deaths and injury. It should be replaced by distinct versions (on right) already used at many hospitals.

Petition to Ban Indistinct Chlorhexidine

Hundreds of patients have been injured and killed because of this completely unnecessary hazard. Pink chlorhexidine antiseptic (centre in image) is indistinct and easily mistaken for other colourless solutions. It’s been accidentally injected into patients spines causing paralysis, legs leading to amputation, and arteries supplying the brain causing agonising death. There’s hundreds of cases (see here). Red chlorhexidine (on right in image) is exactly the … Continue reading Petition to Ban Indistinct Chlorhexidine