Blame--Do You Know It When You See It?

The landmark Institute of Medicine Report, To Err Is Human: Building a Safer Health Care System. stated that medical error causes 44,000 to 98,000 deaths per year. There is no question that the report raised awareness of patient safety and stressed the importance of patient outcomes. Heightened awareness has produced a patient safety industry of sorts, with solutions that range from technology to outcomes measurement. Regulatory bodies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), have recognized the need for patient safety to be embedded in the culture of healthcare organizations. In particular, the JCAHO has encouraged use of the root cause analysis process for investigating near miss and adverse events. This process emphasizes learning from system analysis over assigning individual blame, an approach used successfully in such high reliability organizations as the aviation industry and the military. Many healthcare organizations have formulated nonpunitive reporting policies to encourage error reporting and to identify systems issues. This article discusses the importance of a work complexity and human factors focus, how blame will continue to surface as patient safety efforts are implemented, and implications for outcomes management

We need to talk about error: causes and types of error in veterinary practice

Patient safety research in human medicine has identified the causes and common types of medical error and subsequently informed the development of interventions which mitigate harm, such as the WHO’s safe surgery checklist. There is no such evidence available to the veterinary profession. This study therefore aims to identify the causes and types of errors in veterinary practice, and presents an evidence based system for their classification. Causes of error were identified from retrospective record review of 678 claims to the profession’s leading indemnity insurer and nine focus groups (average N per group=8) with vets, nurses and support staff were performed using critical incident technique. Reason’s (2000) Swiss cheese model of error was used to inform the interpretation of the data. Types of error were extracted from 2978 claims records reported between the years 2009 and 2013. The major classes of error causation were identified with mistakes involving surgery the most common type of error. The results were triangulated with findings from the medical literature and highlight the importance of cognitive limitations, deficiencies in non-technical skills and a systems approach to veterinary error

Drugs in Aviation - A Review

The Aviation Medicine Department of the South African Civil Aviation Authority (SACAA), Aviation Medical Examiners (AME), and Institute for Aviation Medicine (IAM) receive numerous inquiries regarding the use of medication in the aviation environment. Flying an aircraft or controlling aircraft on the ground are highly demanding cognitive and psychomotor tasks, performed in an often inhospitable environment, with exposure to various sources of stress. It is therefore important for aviation personnel (i.e. aviation medical examiners, pilots, cabin crew and air traffic services personnel) to consider the effects that medicine or drugs may have on performance. Studies confirm that some pilots, and other crew members while on duty, used prohibited medications or illegal substances or performed duties while suffering significant unreported medical conditions. When considering aircraft mishaps and their causes, we tend to focus on the pilot. After all, he's in the driver's seat, there to troubleshoot any problems that may arise, and he's expected to bring the “on-loan” aircraft back to base, in one piece, after a mission. If a mishap occurs, investigators look for causes related to pilot error along with evidence of mechanical failure, weather factors, and runway condition and air traffic control (ATC) issues. Reviews of data from general aviation, commercial and military aircraft mishaps show that the two most often cited causal issues are pilot error and mechanical/logistical factors. If pilot error was identified, the question now arises: Are some instances of incorrect controlling of an aircraft due to human factors, such as poor diet or insufficient rest (self-imposed), fatigue, poor concentration, shift-work problems, inadequate training or lack of motivation? More specifically, the following in terms of pilot error have been identified in the USA: • Flying under the influence of alcohol – 15% • Conducting unwarranted manoeuvers – 30% • Penetrating known adverse weather conditions beyond pilot and aircraft capabilities – 40% • Drug impairment of the pilot (includes prescribed medication) – 6% • Miscellaneous – 9% Although these statistics relate to the pilot, they can no doubt be extended to other aviation personnel e.g. ATC, cabin crew (CC) and aircraft maintenance officers (AMO). Of note is that up to 6% of aircrew are ‘under the influence of medication' while operating an aircraft. Aircrew, like all of us, are prone to illness, but those who take medicine on an inadequately informed basis or undertake self-medication, not only endanger their lives but also jeopardise the safety of passengers and costly aircraft. The Aviation Medicine Department of the South African Civil Aviation Authority, Aviation Medical Examiners, and the Institute for Aviation Medicine receive numerous inquiries regarding the use of medication in the aviation environment. In addition, reports have been received relating to aviation personnel using unapproved medication or illegal drugs. Furthermore, a physician may prescribe medication for a patient while being unaware that the patient is performing duties within the aviation environment. Or, a pilot self-medicates because consulting an AME may result in flying privileges being withdrawn. Flying an aircraft or controlling aircraft on the ground are highly demanding cognitive and psychomotor tasks, performed in an inhospitable environment, with exposure to various sources of stress. It is therefore important for aviation personnel (i.e. aviation medical examiners, pilots, cabin crew and air traffic controllers) and non-aviation medical examiners to consider the effect that medicine or drugs may have on aviation performance. A study performed in 1994 by the FAA revealed that an estimated 14 000 US pilots flew while using prohibited medications or illegal substances or flew with significant unreported medical conditions.1 Greater understanding of the effects of medication in humans, and advances in drug development have now made possible the use of various medications by aircrew. In this context assessment of side effects which a drug may have on performance, has become an important part of its clinical profile and provides increased and more informed availability of potential therapy for aircrew. The aim of this review is to make the non-aviation medical examiner aware of, and to provide an understanding of the issues involved rather than to provide recommendations for drug use in aviation and to outline the various approaches that can be adopted to assess whether a drug can be used safely.South African Family Practice Vol. 49 (9) 2007: pp. 4

The effect of human saliva compared to Aloe vera on wound healing of 2nd degree burn injury in animal models

Burn injury is one of the common causes of injury that has relatively high morbidity and mortality. Several studies using herbal and traditional medicine from different countries have been documented in burn injury management. Human saliva that contains antibacterial, antifungal, antiviral and analgesic components as well as growth factors can induce re-epithelialization process in 2nd degree burn injury. Whereas, Aloe vera that influence a physiological moist condition was proven can induce re-epithelialization process lead to faster wound healing. This study aimed to compare topical application of human saliva and A. vera on wound healing process of 2nd degree burn injury. This was an experimental study using post-test only control group design using 27 white rats (Rattus novergicus) of Sprague Dawley strain divided into 3 groups with 9 rats in each group. Group I were applied 1 mL of human saliva, Group II were applied A. vera and Group III as control were applied NaCl. Change in body weight and macroscopic clinical assessment were observed every day for 14 days, whereas histological examination was observed on day 14. The data were presented as mean ± standard error of the mean (SEM) and analyzed using one-way analysis of variance (Anova). The result showed that the wound healing process at each treatment showed different level. The human saliva application tended to show faster wound healing process of 2nd degree burn injury compare with A. vera or NaCl (

Prescribing errors : what’s the story?

Although prescribing errors are one of the most common causes of preventable iatrogenic injury, there have been relatively few studies of their incidence and causes. The majority of the studies that have been carried out have been based in secondary care. This paper reviews what is currently known about prescribing errors. It is suggested that prescribing errors occur in at least 1-2% of all medication orders written, cause harm in about 1% of admissions, and have a wide range of causes. Organisation-wide interventions and cultural changes are likely to be required to prevent them. However, useful first steps suggested include reporting prescribing errors identified, formally reviewing pharmacists’ interventions and developing increased ‘error awareness’ amongst all health care professionals.peer-reviewe

Evidence-Based Healthcare: The Importance of Effective Interprofessional Working for High Quality Veterinary Services, a UK Example

<p class="AbstractSummary"><strong>Objective: </strong></p><p class="AbstractSummary">To highlight the importance of evidence-based research, not only for the consideration of clinical diseases and individual patient treatment, but also for investigating complex healthcare systems, as demonstrated through a focus on veterinary interprofessional working.</p><p class="AbstractSummary"><strong>Background:</strong></p><p class="AbstractSummary">Evidence-Based Veterinary Medicine (EBVM) was developed due to concerns over inconsistent approaches to therapy being delivered by individuals. However, a focus purely on diagnosis and treatment will miss other potential causes of substandard care including the holistic system. Veterinary services are provided by interprofessional teams; research on these teams is growing.</p><p class="AbstractSummary"><strong>Evidentiary value:</strong></p><p class="AbstractSummary">This paper outlines results from four articles, written by the current authors, which are unique in their focus on interprofessional practice teams in the UK. Through mixed methods, the articles demonstrate an evidence base of the effects of interprofessional working on the quality of service delivery.</p><p class="AbstractSummary"><strong>Results:</strong></p><p class="AbstractSummary">The articles explored demonstrate facilitators and challenges of the practice system on interprofessional working and the outcomes, including errors. The results encourage consideration of interprofessional relationships and activities in veterinary organisations. Interprofessional working is an example of one area which can affect the quality of veterinary services.</p><p class="AbstractSummary"><strong>Conclusion: </strong></p><p class="AbstractSummary">The papers presented on veterinary interprofessional working are an example of the opportunities for future research on various topics within evidence-based healthcare.</p><p class="AbstractSummary"><strong>Application:</strong></p><p class="AbstractSummary">The results are pertinent to members of veterinary teams seeking to improve their service delivery, to educators looking to enhance their students’ understanding of interprofessional working, and to researchers, who will hopefully be encouraged to consider evidence-based healthcare more holistically. </p><br /> <img src="https://www.veterinaryevidence.org/rcvskmod/icons/oa-icon.jpg" alt="Open Access" /> <img src="https://www.veterinaryevidence.org/rcvskmod/icons/pr-icon.jpg" alt="Peer Reviewed" /

Prevalence and causes of prescribing errors: the prescribing outcomes for trainee doctors engaged in clinical training (PROTECT) study

Objectives Study objectives were to investigate the prevalence and causes of prescribing errors amongst foundation doctors (i.e. junior doctors in their first (F1) or second (F2) year of post-graduate training), describe their knowledge and experience of prescribing errors, and explore their self-efficacy (i.e. confidence) in prescribing. Method A three-part mixed-methods design was used, comprising: prospective observational study; semi-structured interviews and cross-sectional survey. All doctors prescribing in eight purposively selected hospitals in Scotland participated. All foundation doctors throughout Scotland participated in the survey. The number of prescribing errors per patient, doctor, ward and hospital, perceived causes of errors and a measure of doctors' self-efficacy were established. Results 4710 patient charts and 44,726 prescribed medicines were reviewed. There were 3364 errors, affecting 1700 (36.1%) charts (overall error rate: 7.5%; F1:7.4%; F2:8.6%; consultants:6.3%). Higher error rates were associated with : teaching hospitals (p&#60;0.001), surgical (p = &#60;0.001) or mixed wards (0.008) rather thanmedical ward, higher patient turnover wards (p&#60;0.001), a greater number of prescribed medicines (p&#60;0.001) and the months December and June (p&#60;0.001). One hundred errors were discussed in 40 interviews. Error causation was multi-factorial; work environment and team factors were particularly noted. Of 548 completed questionnaires (national response rate of 35.4%), 508 (92.7% of respondents) reported errors, most of which (328 (64.6%) did not reach the patient. Pressure from other staff, workload and interruptions were cited as the main causes of errors. Foundation year 2 doctors reported greater confidence than year 1 doctors in deciding the most appropriate medication regimen. Conclusions Prescribing errors are frequent and of complex causation. Foundation doctors made more errors than other doctors, but undertook the majority of prescribing, making them a key target for intervention. Contributing causes included work environment, team, task, individual and patient factors. Further work is needed to develop and assess interventions that address these.</p

Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations