Combating omission errors through task analysis and good reminders.
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Leaving out necessary task steps is the single most common human error type. Certain task steps possess characteristics that are more likely to provoke omissions than others, and can be identified in advance. The paper reports two studies. The first, involving a simple photocopier, established that failing to remove the last page of the original is the commonest omission. This step possesses four distinct error-provoking features that combine their effects in an additive fashion. The second study examined the degree to which everyday memory aids satisfy five features of a good reminder: conspicuity, contiguity, content, context, and countability. A close correspondence was found between the percentage use of strategies and the degree to which they satisfied these five criteria. A three stage omission management programme was outlined: task analysis (identifying discrete task steps) of some safety critical activity; assessing the omission likelihood of each step; and the choice and application of a suitable reminder. Such a programme is applicable to a variety of healthcare procedures. (+info)
Improving safety on the front lines: the role of clinical microsystems.
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The clinical microsystem puts medical error and harm reduction into the broader context of safety and quality of care by providing a framework to assess and evaluate the structure, process, and outcomes of care. Eight characteristics of clinical microsystems emerged from a qualitative analysis of interviews with representatives from 43 microsystems across North America. These characteristics were used to develop a tool for assessing the function of microsystems. Further research is needed to assess microsystem performance, outcomes, and safety, and how to replicate "best practices" in other settings. (+info)
Leading organisational learning in health care.
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As healthcare organisations seek to enhance safety and quality in a changing environment, organisational learning practices can help to improve existing skills and knowledge and provide opportunities to discover better ways of working together. Leadership at executive, middle management, and local levels is needed to create a sense of shared purpose. This shared vision should help to build effective relationships, facilitate connections between action and reflection, and strengthen the desirable elements of the healthcare culture while modifying outdated assumptions, procedures, and structures. (+info)
Pushing the profession: how the news media turned patient safety into a priority.
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The problem of patient safety has been repeatedly identified in the medical literature since the mid 1950s, but regular revelations about patient deaths and injuries resulting from treatment have had almost no effect on the actual practice of medicine. Only very recently has the medical profession made a systematic effort to reduce or eliminate the many preventable deaths and injuries that occur in hospitals each year. This review traces the diffusion of innovation in medical error reduction to the public shaming of the profession that occurred as a result of stories that appeared in the news media. The focus is on the USA, but news stories about patient safety are sparking a similar process throughout the western world. (+info)
Decision support and safety of clinical environments.
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Safety in the clinical environment is based on structures that reduce the probability of harm, on evidence that enhances the likelihood of actions that increase favourable outcomes, and on explicit directions that lead to decisions to implement the actions dictated by this evidence. A clinical decision error rate of only 1% threatens patient safety at a distressing frequency. Explicit computerised decision support tools standardise clinical decision making and lead different clinicians to the same set of diagnostic or therapeutic instructions. They have favourable impacts on patient outcome. Simple computerised algorithms that generate reminders, alerts, or other information, and protocols that incorporate more complex rules reduce the clinical decision error rate. Decision support tools are not new; it is the new attributes of explicit computerised decision support tools that deserve identification. When explicit computerised protocols are driven by patient data, the protocol output (instructions) is patient specific, thus preserving individualized treatment while standardising clinical decisions. The expected decrease in variation and increase in compliance with evidence-based recommendations should decrease the error rate and enhance patient safety. (+info)
Patient safety: what about the patient?
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Plans for improving safety in medical care often ignore the patient's perspective. The active role of patients in their care should be recognised and encouraged. Patients have a key role to play in helping to reach an accurate diagnosis, in deciding about appropriate treatment, in choosing an experienced and safe provider, in ensuring that treatment is appropriately administered, monitored and adhered to, and in identifying adverse events and taking appropriate action. They may experience considerable psychological trauma both as a result of an adverse outcome and through the way the incident is managed. If a medical injury occurs it is important to listen to the patient and/or the family, acknowledge the damage, give an honest and open explanation and an apology, ask about emotional trauma and anxieties about future treatment, and provide practical and financial help quickly. (+info)
Modeling the interactions of Lactobacillus curvatus colonies in solid medium: consequences for food quality and safety.
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The growth process of Lactobacillus curvatus colonies was quantified by a coupled growth and diffusion equation incorporating a volumetric rate of lactic acid production. Analytical solutions were compared to numerical ones, and both were able to predict the onset of interaction well. The derived analytical solution modeled the lactic acid concentration profile as a function of the diffusion coefficient, colony radius, and volumetric production rate. Interaction was assumed to occur when the volume-averaged specific growth rate of the cells in a colony was 90% of the initial maximum rate. Growth of L. curvatus in solid medium is dependent on the number of cells in a colony. In colonies with populations of fewer than 10(5) cells, mass transfer limitation is not significant for the growth process. When the initial inoculation density is relatively high, colonies are not able to grow to these sizes and growth approaches that of broth cultures (negligible mass transfer limitation). In foods, which resemble the model solid system and in which the initial inoculation density is high, it will be appropriate to use predictive models of broth cultures to estimate growth. For a very low initial inoculation density, large colonies can develop that will start to deviate from growth in broth cultures, but only after large outgrowth. (+info)
Randomised factorial trial of falls prevention among older people living in their own homes.
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OBJECTIVE: To test the effectiveness of, and explore interactions between, three interventions to prevent falls among older people. DESIGN: A randomised controlled trial with a full factorial design. SETTING: Urban community in Melbourne, Australia. PARTICIPANTS: 1090 aged 70 years and over and living at home. Most were Australian born and rated their health as good to excellent; just over half lived alone. INTERVENTIONS: Three interventions (group based exercise, home hazard management, and vision improvement) delivered to eight groups defined by the presence or absence of each intervention. MAIN OUTCOME MEASURE: Time to first fall ascertained by an 18 month falls calendar and analysed with survival analysis techniques. Changes to targeted risk factors were assessed by using measures of quadriceps strength, balance, vision, and number of hazards in the home. RESULTS: The rate ratio for exercise was 0.82 (95% confidence interval 0.70 to 0.97, P=0.02), and a significant effect (P<0.05) was observed for the combinations of interventions that involved exercise. Balance measures improved significantly among the exercise group. Neither home hazard management nor treatment of poor vision showed a significant effect. The strongest effect was observed for all three interventions combined (rate ratio 0.67 (0.51 to 0.88, P=0.004)), producing an estimated 14.0% reduction in the annual fall rate. The number of people needed to be treated to prevent one fall a year ranged from 32 for home hazard management to 7 for all three interventions combined. CONCLUSIONS: Group based exercise was the most potent single intervention tested, and the reduction in falls among this group seems to have been associated with improved balance. Falls were further reduced by the addition of home hazard management or reduced vision management, or both of these. Cost effectiveness is yet to be examined. These findings are most applicable to Australian born adults aged 70-84 years living at home who rate their health as good. (+info)