A modified critical-incident analysis technique was used in a retrospective examination of the characteristics of human error and equipment failure in anesthetic practice. The objective was to uncover patterns of frequently occurring incidents that are in need of careful prospective investigation. Forty seven interviews were conducted with staff and resident anesthesiologists at one urban teaching institution, and descriptions of 359 preventable incidents were obtained. Twenty three categories of details from these descriptions were subjected to computer-aided analysis for trends and patterns. Most of the preventable incidents involved human error (82%), with breathing-circuit disconnections, inadvertent changes in gas flow, and drug syringe errors being frequent problems. Overt equipment failures constituted only 14% of the total number of preventable incidents, but equipment design was indictable in many categories of human error, as were inadequate experience and insufficient familiarity with equipment or with the specific surgical procedure. Other factors frequently associated with incidents were inadequate communication among personnel, haste or lack of precaution, and distraction. Results from multi-hospital studies based on the methodology developed could be used for more objective determination of priorities and planning of specific investments for decreasing the risk associated with anesthesia.

Preventable Anesthesia Mishaps: A Study of Human Factors

https://interruptions.net/literature/Grundgeiger-IntJMedInformat09.pdf

Interruptions in healthcare: Theoretical views

The Dynamic Multiprocess Framework: Evidence from prospective memory with contextual variability

Checklists are common in some medical fields, including surgery, intensive care and emergency medicine. They can be an effective tool to improve care processes and reduce mortality and morbidity. Despite the seemingly rapid acceptance and dissemination of the checklist, there are few studies describing the actual process of developing and implementing such tools in health care. The aim of this study is to explore the experiences from checklist development and implementation in a group of non-medical, high reliability organisations (HROs). A qualitative study based on key informant interviews and field visits followed by a Delphi approach. Eight informants, each with 10-30 years of checklist experience, were recruited from six different HROs. The interviews generated 84 assertions and recommendations for checklist implementation. To achieve checklist acceptance and compliance, there must be a predefined need for which a checklist is considered a well suited solution. The end-users ("sharp-end") are the key stakeholders throughout the development and implementation process. Proximity and ownership must be assured through a thorough and wise process. All informants underlined the importance of short, self-developed, and operationally-suited checklists. Simulation is a valuable and widely used method for training, revision, and validation. Checklists have been a cornerstone of safety management in HROs for nearly a century, and are becoming increasingly popular in medicine. Acceptance and compliance are crucial for checklist implementation in health care. Experiences from HROs may provide valuable input to checklist implementation in healthcare.

/pdf/implementation-of-checklists-in-health-care-learning-from-579c6y8kun.pdf

Implementation of checklists in health care; learning from high-reliability organisations

Globally, health systems face constraints and challenges around patient safety and quality, lack of human resources, and rising moral distress among nurses. This concern about the gap in quality and patient safety and the need for improvement was highlighted more than a decade ago in two landmark studies by the Institute of Medicine (IOM): To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century. These reports were followed by a staggering number of scholarly publications, improvement initiatives, and the establishment of various institutions on patient safety. In 2004, the World Alliance for Patient Safety was launched to advance the goal of patient safety, to coordinate patient safety initiatives globally, and to reduce the impact of unsafe healthcare through a number of systemic programs (e.g. mobilizing patients and organizations for patient safety, addressing taxonomy, research, development, and reporting of learning systems). Additionally, an ad hoc expert group of the Alliance produced a report summarizing the evidence on patient safety, which highlighted structural, process, and outcome gaps in need of further research (e.g. safety culture, organizational determinants, structural accountability, lack of patient involvement in patient safety, adverse events, injuries related to drug treatment, and medical devices). Furthermore, the report highlighted the burden in terms of morbidity and mortality posed by unsafe healthcare globally, lack of available data from developing countries around structural and process factors contributing to unsafe care, and the applicability of data derived predominantly from developed countries to local conditions in developing countries. Recommendations were made for a better understanding of the epidemiology of adverse events and processes contributing to them in developing countries. In nursing, the response from the profession to the call for patient safety and quality has been remarkable. In an evidence-based handbook for nurses, Hughes highlighted nursing’s contributions to patient safety and quality, evidence-based practice, patient-centered care, improvement in working conditions, and the work environment for nurses, and discussed a number of opportunities for further improvement and research. Furthermore, nurses’ continuing contributions span a broad range of initiatives in practice (e.g. patient advocacy and attentiveness training and nurse-led quality improvement), education (e.g. curriculum changes to target core competencies such as evidence-based practice, informatics, and quality improvement), and research using a number of conceptual and empirical methodologies to explicate, analyze, and synthesize data and to implement and evaluate interventions (e.g. nurse-led clinics, tele-health, and care pathways). In addition, nurse leaders and nursing governing bodies responded with a number of position papers, revision of policies and Code of Ethics, and accreditation and regulatory initiatives, to demonstrate the profession’s commitment to patient safety and quality. Although there has been some progress, more still needs to be done.

https://journals.sagepub.com/doi/pdf/10.1177/0969733013509042

Patient safety and quality in healthcare Nursing ethics for ethics quality

This study investigated failures of prospective memory (PM) as a relevant but neglected error type in medicine. A patient simulator was used to investigate PM failures. The influence of subjective ...

Prospective memory failures as an unexplored threat to patient safety: results from a pilot study using patient simulators to investigate the missed execution of intentions.

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Prospective memory failures as an unexplored threat to patient safety: results from a pilot study using patient simulators to investigate the missed execution of intentions.