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Human factors, patient safety and quality improvement
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
Developed in 1931, Heinrich's safety pyramid (Figure13.2) theorised that unsafe acts or near misses lead to minor injuries and, over time, to a major injury. The accident pyramid proposes that for every 300 near misses there are 29 minor injuries and one major injury. Risk assessment, which is a step in risk management that calculates the value of risk related to a situation or hazard, has shown us that what prevents patients from being hurt is not only by reducing the number of mistakes but rather by increasing the number of defences set up against the consequences of mistakes. The key message is that near misses provide the best data about the reliability of safety systems. It is, therefore, most important to report near misses as well as adverse events to ensure that defences against adverse events are built and sustained.
Understanding the difference between blame and accountability, and applying learning organisation principles
Published in Denise Chaffer, Baroness Emerton, Effective Leadership, 2016
Commercial industries such as oil and gas have a culture in which it is not accepted that incidents are inevitable and not preventable. They apply a position of zero tolerance to incidents, which focuses them more specifically on the root cause. These root causes inevitably fall into categories of the need to make a change in behaviour, procedure or material. They advocate shifting the focus from reporting and processing incidents to one of mastering the study of ‘near misses’, which they believe provide the best intelligence in prevention and learning, and implementing predictive techniques to reduce harm. This approach is wholly compatible with learning from system failure and understanding human factors, but with far greater focus on taking the action needed to rectify the situation and reduce risk.
Apologising for Mistakes
Published in Muhammed Akunjee, Nazmul Akunjee, Shoaib Siddiqui, Ali Sameer Mallick, The Easy Guide to OSCEs for Communication Skills, 2010
Muhammed Akunjee, Nazmul Akunjee, Shoaib Siddiqui, Ali Sameer Mallick
When mistakes occur, one should complete a clinical incident form. The term ‘clinical incident’ is an umbrella term used to describe events which have or had the potential to cause unintentional physical or mental harm. An ‘adverse event’ is one in which such harm has taken place, whereas ‘near miss’ describes an event where no harm has occurred but could easily have done so.
Investigating barriers to accident precursor reporting in East Azerbaijan Province Gas Company from the perspective of HSE officers: a qualitative study
Published in International Journal of Occupational Safety and Ergonomics, 2022
Rasoul Ahmadpour-Geshlagi, Neda Gilani, Saber Azami-Aghdash, Mostafa Javanmardi, Seyed Shamsaledin Alizadeh, Saeid Jalilpour
Iran National Gas Company is one of the major national companies whose activities have many hazards. In this company, as in many large companies, accident precursor reporting has been considered. The purpose of accident precursor reporting is to prevent accidents and reduce damage to employees, environment, assets and reputation. For this purpose, the instructions for reporting anomalies in this company have been published and communicated to all provincial gas companies. An anomaly refers to any unsafe conditions or acts in the workplace. For this purpose, the instructions for reporting anomalies in this company have been prepared and communicated to all related provincial gas companies. There are four important terms in these instructions that are mentioned here. An anomaly refers to any unsafe conditions or acts in the workplace. An incident is an event that has harmed people or damaged equipment, property and the environment, or could have led to them. A near miss is an event that can lead to illness, injury or damage to facilities, the environment, the reputation of a company and business losses, but does not. In fact, any event that has the potential to cause injury or damage or loss, but does not occur under certain conditions, is called a near miss. An accident is an incident that has resulted in injury to people or damage to equipment, property and the environment.
Construction safety performance measurement using a leading indicator-based jobsite safety inspection method: case study of a building construction project
Published in International Journal of Occupational Safety and Ergonomics, 2022
Kishor Bhagwat, Venkata Santosh Kumar Delhi, Prakash Nanthagopalan
Several methods have been proposed to utilize leading indicators for SPM. While some methods use investigation of near misses, other methods concentrate on behavior-based safety measurement. Further, surveys to understand safety perception and jobsite safety inspection (JSI) were proposed in leading indicator-based SPM methods. A near miss is defined as an unplanned event not resulting in an injury or illness but that has the potential to do so [38]. Chan et al. [39] adopted a near miss method to improve the safety performance of the electrical and mechanical works in repair, maintenance, alteration and addition projects. However, SPM systems based on near miss incidents often lack clarity in defining near miss and reporting issues [29]. The behavior-based safety method follows various steps such as observing employees’ behavior for a certain period (weeks or months), identifying unsafe behaviors, providing feedback and safety intervention strategies to employees, and capturing employees’ behavior again. For example, Lingard and Rowlinson [40] adopted a behavior-based safety method in the Hong Kong construction industry and noticed safety performance enhancement in crucial areas such as site housekeeping. This method provides a detailed investigation into employee behavior but is often labor-intensive and expensive in terms of the time and costs involved [29]. Further, the meticulous observation may capture the workers’ altered behavior due to phenomena like the Hawthorne effect [29]. The safety perception survey method is a widely adopted method to understand construction safety performance. For example, Patel and Jha [15] adopted the safety perception survey method to investigate the determinants of construction safety performance. However, safety perception suffers from problems of biased feedback from workers apart from the complexities involved in the appropriate design of a questionnaire to capture and analyze worker perceptions [29]. Finally, JSI also provides a unique way to capture the assessment of construction safety through an extensive checklist and descriptive assessment [29]. JSI is usually carried out by safety experts to provide a quick way to assess safety, thus helping in framing safety improvement strategies to track performance. However, leading indicator-based JSI is understudied and remains a crucial gap in research on safety measurement utilizing leading indicators. The present study aimed at fulfilling this gap.
Barriers to Self-Reporting Patient Safety Incidents by Paramedics: A Mixed Methods Study
Published in Prehospital Emergency Care, 2018
Julie E. Sinclair, Michael A. Austin, Christopher Bourque, Jennifer Kortko, Justin Maloney, Richard Dionne, Andrew Reed, Penny Price, Lisa A. Calder
The results of this study reveal that a high proportion of fear-based barriers exist to self-reporting of PSIs by paramedics. The most significant barriers were the fear of being: punished, deactivated, decertified, suspended, and terminated. Yet, despite these fears, paramedics still report that they are likely to self-report critical PSIs. A concerning proportion of paramedics admit to falsifying documentation (14.0%). This behavior raises professionalism concerns and potential risks to patient safety and can reasonably be assumed to be attributed to the prominent fear of punishment that pervaded the responses. Our results underpin the urgent need for a change in culture to facilitate future identification of PSIs. This “need” was also echoed in the results of the qualitative analysis, with a “change in culture” emerging as the central theme along with 7 recommendations to address the barriers to self-reporting PSIs: eliminate fear, reduce uncertainty, increase accessibility, educate, build better relationships, provide feedback, and promote an environment for shared learning. By addressing these barriers and increasing self-reporting rates, we could increase opportunities for shared learning and facilitate the ability to implement changes within the system to prevent recurrence of events. Near misses are often overlooked since there is no harm to the patient, as evidenced by responses in our qualitative data and quantitative data (only 22.8% of respondents would have self-reported the near miss). Providing education around the importance and purpose of reporting near misses could have a large impact on improving patient safety, since, as some research has reported, near miss events vastly out-number adverse events and because medical errors and other patient safety events are often preceded by near miss events (24). Recognizing and reporting near misses is a proactive patient safety strategy that, if effectively addressed, can prevent future recurrence of similar events as well as future harmful events while adding more value to quality improvement. The need to “develop better relationships” theme, specifically more trusting relationships, aligns well with the Just Culture movement in healthcare; a movement, pioneered by safety expert David Marx, that has redefined accountability (25). A balanced approach to human and system accountability, where EMS providers/paramedics feel safe to report safety incidents, will, ultimately, improve the quality of care provided, and patient safety (26).