If patient safety is to improve healthcare needs to change. The historical top down approach which has hindered improvement requires a transition into one where decisions are driven from the front line. Those corporations who’ve introduced front line driven frameworks (e.g. Toyota Production System – see here) provide the highest quality in […]

Front line work environments are full of unnecessary distractions detracting focus from the task at hand.  They come in many forms from a noisy vacuum cleaner disrupting a patient consult, to a poorly designed electronic medical recording system. Dr Gordon Caldwell has presented much work specifically looking at how distraction […]

If you went skydiving, would you first ask for scientific evidence from a randomized trial that a properly functioning parachute prevents injury before you’d consider using one during your freefall? Probably not. In fact, no such study exists. Of course, some people without a parachute have survived a freefall from […]

Even when there’s overall agreement a proposed intervention will improve patient safety there’s one word which can stop its implementation. This word is most often used by those in authority – in accepting the intervention they’ll need to accept the previous way they presided over wasn’t as good. The ‘C’ […]

It’s counter-intuitive that an alert designed to improve safety may actually be detrimental to patient care. Unfortunately alerts on their own may absolve governing bodies from ensuring more effective interventions. The diagram below (created by Cassie McDaniel) neatly demonstrates which interventions are most effective at improving safety. Forcing functions represent […]

When an aeroplane crashes hundreds often die. This concentration of deaths lends the aviation industry tremendous energy in ensuring the same adverse event doesn’t happen again. Healthcare rarely benefits from the same fate. ‘Over the last few years NSW Health have received numerous reports of death and morbidity from central […]

Recently a tragic mix up where oxygen tubing was connected to a urinary catheter resulted in the death  of ex-Socceroo Steve Herczeg (see here). ‘How can anyone make this mistake?’ Unfortunately events like this occur regularly – we often only here of them via the media – our error report […]

One major objective of a ‘Root Cause Analysis’ is to: ‘Look for improvements rather than apportion blame’ Recently, a tragic gas pipeline crossover resulted in death of a newborn, and left another with severe brain injury. Prior to this incident many clinicians believed pipeline errors had been relegated to history. Unfortunately pipeline […]