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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

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

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

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

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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