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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

We’re Rooted

  In this series of posts under the heading ‘we’re killing our patients’ we explore why clinical error remains the third greatest killer in hospitals (greater than sepsis and trauma). In many healthcare reporting systems adverse events which are sufficiently severe and likely to recur are subjected to a Root Cause Analysis (RCA). Root Cause Analysis Definition: ‘A method used to investigate and analyse incidents … Continue reading We’re Rooted

No one else has complained about it

In this series of posts under the banner we explore why clinical error remains the third greatest killer in our hospitals. When you present a clinical hazard you may receive this comment in reply: ‘No one else has complained about it’ There are two sides to this: 1. Few may have actually made a complaint about the issue. Does this mean that there isn’t a … Continue reading No one else has complained about it

Prudence is seen as a virtue

Prudence is a virtue except when we’ve become the third greatest killer in hospitals. In this series of posts in under the banner ‘we’re killing our patients’, we explore why healthcare frameworks may actually be detrimental to introducing safety solutions. In 2000, a report from the United Kingdom found that medical errors caused harm (death and injury) to in excess of 850,000 patients admitted to … Continue reading Prudence is seen as a virtue

I can’t work with you any more

I can’t work with you any more. These were the words uttered to me by a colleague that I have warmed to over the past few years. He had come across my website and enquired if I had anything to do with it. I can’t work with you any more. He said those words in relation to things I had written about a specific unsafe … Continue reading I can’t work with you any more

Solution Feedback Loop

We need something much greater than an incident reporting system. Clinical error is the third biggest killer in hospitals. Healthcare is a risky business. Simply being in an acute care hospital in Florida carries, on average, a 2000 fold greater risk of dying from the acute care process than air travel. (Dr Paul Barach) We need a solution feedback loop driven by teams of human … Continue reading Solution Feedback Loop

Human Factors

The Quality in Australian Healthcare Study found adverse events (unintended injury or complication caused by healthcare) occurred in 16.6% of hospital admissions, with 51% of these adverse events judged to be “highly preventable”. Death occurred in 4.9% of patients suffering an adverse event, and permanent disability in 13.7%. (Heard – Errors in Medicine: A Human Factors Perspective) In this series of posts we explore why … Continue reading Human Factors

Beneath the Radar

Clinical error is the third biggest killer in hospitals – more than breast cancer and trauma. Professor Bill Runciman says of Australian healthcare ‘Without re-design the system will continue with relentless inefficiency to kill 10,000 patients and generate 500,000 adverse events ….’ In this series of posts we explore how frameworks in healthcare may be detrimental to delivering effective safety solutions, and provide avenues to … Continue reading Beneath the Radar

Latent Errors – Equipment

Research has shown that 11% of NHS patients experience an adverse event, half of which are preventable, and a third of which lead to either serious complications or death.  Lord Hunt and Professor Rory Shaw have used this study to project annual totals of 400,000 preventable adverse events and 34,000 deaths. (From Improving Patient Safety – ECRI, 2001) In this series of posts under the … Continue reading Latent Errors – Equipment