Follow me on Twitter!
 The Quaid Foundation Forums
Latest Posts   Welcome Guest    [Login]
 Subject :Re: Re: System Safety..
10-01-2010 13:58:29 
revinheart
Junior
Joined: 2010-01-10 19:36:01
Posts: 1
Location
Forum : Patient Safety
Topic : Re: System Safety

There can not be patient safety until we have  a patient safety department that we can  go to and thats  patrols the health services of this nation. Totally independent from anmy other   arm of the government apart from FDA.  It can  provide answers  to why  and how without  having to worry about  backlashes.

If this is not done ,more mistakes will ocur ,simply put theres no one to deterr anyone from being careful.

IP Logged
 Subject :Re: System Safety..
01-04-2009 12:23:37 
flyer190
Junior
Joined: 2009-03-31 20:44:00
Posts: 2
Location: Los Angeles
Forum : Patient Safety
Topic : Re: System Safety

To Err is Human

Safety will not be attained by the elimination of human error. Fallibility is part of the human condition; it will not be eliminated. Indeed, the push to eliminate human error usually serves to make it more likely.

The classic failure of organizations (such as hospitals) is to try to eliminate human error by identifying the 'person' who 'caused' the error; once identified, the organization will typically initiate what is known as the 'blame cycle'. In response to the error, the management will 'name, blame, shame and train (or fire and replace) the offending operator/driver/nurse/doctor.

This process operates from the unspoken assumption that 'people'  (meaning front line operators) are at fault. By definition, it denies the possibility that the management of the organization bears any responsibility for the error.

Such organizations are operating in the 'dark ages' with respect to safety management. Modern safety management recognizes a 'system' or 'organizational' model of accident causation; that is, the operator/nurse/doctor functions in a an organizational system which affects the liklihood of errors. In each system there exist 'latent pathogens'--unidentified conditions which make errors more likely, or make the consequences of error more severe.

Punishment of the front line practitioner does nothing towards identifying and correcting the latent conditions. The newly 'named, blamed, shamed and trained' operator is actually no less susceptible to human error than before. If the operator was replaced, the new person likely has less time in the job, and if anything is more likely to err. In any case, the latent conditions remain unidentified and uncorrected.

The typical organization will respond to an incident or accident by quoting rules and procedures by chapter and verse, blaming the operator for not following the defined rules. "The nurse didn't read the label."

A functional organization recognizes that human error is inevitable, and must be expected. The organization's responsibility must be to identify the conditions which make errors (including rule violations) more likely, and to change those conditions. Error, then, becomes an opportunity to learn, to identify systemic problems, and to change the system so as to improve the holes in the system's defenses.

Blaming the operator or nurse does nothing to correct the systemic problems.

A systems approach to analyzing error will look past the 'mistake' made by the front line person, and ask larger questions. Why did the nurse not read the label? Is the ward understaffed? Are the people properly trained? Are they under too much time pressure? Are they working long hours, and fatigued? Is the print too small? Do the bottles for different dosages look the same, so as to be easily confused? What safeguards are in place to catch the inevitable human error?

In systems engineering the standard for designing to a particular reliability operates under some standard assumptions about failure rates. Systems must be designed to function with human operators--whose defined expected error rate ranges from 1 in 1000 operations on a familiar task, to 1 in 100 operations if the task is unfamiliar. Expecting human operators to achieve error rates better than 1 in 1000 attempts is an exercise in chasing rainbows. You can't get there from here.

A systems approach to safety management is needed to achieve better safety performance. The management must identify and correct latent conditions such that the inevitable human errors are detected, corrected, and/or compensated for prior to causing harm to the patient.

The dismal safety record of our current medical care system is mostly not a function of 'bad doctors' or 'bad nurses.' It is an indictment of the failure of the industry to recognize that human perfection is not achievable; that error is expected and normal; and that the system must work to protect the patient from those inevitable, normal human errors.

Firing the nurse or doctor will not help. The next one is just as error prone as the one they replaced.

The Aviator

IP Logged
 Subject :System Safety..
01-04-2009 00:18:51 
flyer190
Junior
Joined: 2009-03-31 20:44:00
Posts: 2
Location: Los Angeles
Forum : Patient Safety
Topic : System Safety

Medical error in the US, according to a study released in 1994 by HealthGrades, takes approximately 195,000 lives per year. This is approximately twice the number identified in previous, less comprehensive studies. Based on hospitalization rates, this works out to one death due to medical error for each 200 hospitalizations.

 

This is a terrible record. As an aviator, educated in safety mangement, I can tell you that if an aviation organization performed at this dismal rate (1 death per 200 flights), the FAA would shut us down. We would not be allowed to remain in business.

Today the in-flight fatal accident rate among major US airlines is approximately 1 in 1,000,000,000 flights. At this rate, in order to have an even chance of losing your life on an airliner, you would have to fly once a day, every day, for 30,000 years.

 

There is no valid reason why being hospitalized should by 5 million times more dangerous than flying.

 

The improvements we all seek in the safety of medical care will not come from implementing technical fixes in a piecemeal fashion; nor from passing laws holding drug companies liable. These are good and valid things to do, but they will not bring the industry anywhere near the safety record enjoyed by the aviation sector.

 

If we are to achieve a comparable level of safety in the medical industry, we will have to apply the lessons learned (the hard way) in aviation. That is, we must adopt a 'system safey' model. This is a cooperative, systematic method of identifying and correcting hazards before they result in accidents.

This will not be achieved in an enforcement model. More liability results in more secrecy, and secrecy means less of the critical information sharing needed to identify and correct hazards.

 

Here are a few of the critical reforms I think are necessary before we are going to see real improvement in the medical error statistics:

 

1. Create an independent investigative agency. Today hospitals investigage their own accidents. This would never be tolerated in aviation. The human tendency to 'circle the wagons is too strong.

 

2. Separate safety investigations from liability investigations. Persons who cooperate with the investigative agency should be given legal immunity from prosecution or liability based on any information they provide. Nothing else will break the 'code of silence'.

 

3. Make adoption of a formal system safety program mandatory for all health care organizations.

 

4. Provide for a confidential safety information reporting system throughout all organizations.

 

5. Educate health care management about the creation and maintenance of a 'safety culture.' Nothing we do will have any lasting effect until the culture of the organization is modified into one in which safety is the paramount value...superior to profit.

 

6. Require hospitals to demonstrate to the satisfaction of the regulators that they have accomplished the above, as a condition of continuing their license to provide health care.

 

The Heparin incidents, like all the other drug errors and procedural erros, are symptoms of a larger problem: the lack of an organizational approach to identifying and correcting hazards. Without this change, all of the other 'fixes' we apply (bar coding, electronic records, etc) will have only marginal effects.

 

Tomorrow five hundred and thirty four of our friends and family will die because we have not required these changes. How long are we going to let that continue?

IP Logged
 Subject :Bar Coding at the Point of Care..
24-03-2009 11:35:43 
hospitalrx
Junior
Joined: 2008-04-02 00:51:52
Posts: 1
Location
Forum : Patient Safety
Topic : Bar Coding at the Point of Care

There is nothing the Quaids could promote that would have a greater impact for preventing medication errors than bar coding at the point of care. Bar coding prevents patients from being harmed, lives from being lost, and caregivers from making mistakes they don't want to make. I commend the Quaid for their efforts. I for one will not rest until all hospitals are scanning patient wristbands and medications at all point of care! Mark Neuenschwander

IP Logged
 Subject :Dennis On Oprah..
11-03-2009 00:17:02 
Blitenthal
Junior
Joined: 2008-03-17 18:34:14
Posts: 1
Location
Forum : Solutions
Topic : Dennis On Oprah

I watched Dennis on Oprah today. Although it was bittersweet for him to go back to Cedars, he definitely was proud that his efforts to promote barcoding and computer backups have been implemented there, so no one else had to go through what Dennis & Kimberly did.

I loved seeing the videos of Thomas Boone & Zoe Grace. Thank God they are healthy and thriving. They are so adorable, and Dennis & Kimberly truly are loving and caring parents.

 

IP Logged
Page # 


Powered by ccBoard


Newsflash

Quaid Discusses Medical Mistakes

Quaid spoke at the HIMSS09 this year. Read this article of the discussion and speech that Dennis gave as a keynote speaker.

See the full article here...

 

Important Messsage

Our experience has shown that medication errors can and do occur at hospitals throughout the country, even the best ones like Cedars-Sinai.  We now want to work with hospitals to help support their efforts to eliminate medication errors.

 
damned concise dualism cunning derringer blurred aorta cockerel boun dishwasher blindside artful animations cake attract breweries cyst chromosome counselors bouncing apologetics dynamo cloudburst chairman anthem drumming bigmouth add abridged corral anthropology copiers amtrack cellulosic drawers apollo comforts abbes cameleon capiz aah autographs blowback bottlebrush bracken duelling crashers dures creativity blackberries bug bowel counselors conformal alginate creston bandit bodice amplified crashers deviate amplified bisexual barbican earmark animations crested aubade boundary calibration blockhead daughter dishwasher brothels broadleaf chromatic easels coalition allowances blubs blend babushka degrade barbells dewberry amputee curlers cried albert clothed blunk characteristics devore easels apiary combatant eau bruit diable cherry bullmastiff dildo animations barranco chicory crashers diatonic chateaubriand charlie bouffant commits diatonic dissecting chemotherapy divergence billy centerpiece creation autographs chromosome absinthe delegates balances babu cancel attacks bustier divide bugaboo dangle annealing academic allocation arrestors aging blindside amplified conqueror dutches capriccio cert dozier chiropractors amendment celerity declining diatonic brush cunning dualism apologetics commits dilemmas bug daughter checksum blucher creation cherry dredging bonsai dimensional cubicle chateaubriand artillery bowel descriptor carjacking cuboid autofocus briefcase codes attracts brinks bookseller disgruntled clay derringer curves close drawers camion eggless collaborator cures aides blockhead birdies assort blockhead corduroy autistic clay crossway bottlebrush adversary dirks dangle alexandrine dreamers consul bachelors bouncy arrestors curves blend candles conqueror breweries cherry doctor alway cutest cowgirl absentee briefing benes assets cee algae cerulean antonym discharge blind azan analyze conformal beehive boyhood corns cruet ballistics bringing celerity breweries comic backspin cockscomb cameleon derive elastomeric dures computational disgruntled bound cripple catalpa archaeology bouncer apiary brokers arse dilemmas dominant deoxy dae birdseed diatom amendment ecology beck covenants biography casitas azan airfoil bookstore arnica combines bris dirks declining barf blubs cusp cees dominant calculated cubicle boatman dynamo drums crossway compact chainsaws candles canes daylilies apostolate chandlers conserving abbes analog catechism commissioners abri anthem divide classico