“Actionability” – the Appropriate and Necessary Outcome of Investigations
In the previous commentary in this series about enhancing the value of investigations, I discussed the findings of an investigation involving missed/delayed diagnosis of acute leukemia. The original...
View ArticleHow to improve incident reporting rates
The core purpose of incident reporting is to learn from what happened in order to make improvements to future healthcare processes and systems and protect patients from harm. However, research1,2 shows...
View ArticleIs it Possible to Modernize How Guidelines and Policies are Stored?
Considering the ubiquity of modern technology and computers, it seems an archaic notion that information such as patient records, healthcare policies, and guidelines would be stored by means of paper...
View ArticleImproving Diagnosis – Modulating “Hidden” Factors, Human and Otherwise
When we try to dissect through the various confounding factors that contribute to delays and errors in diagnosis, it is important to understand that only by delving deeply can one realize opportunities...
View ArticleCan Healthcare Investigations Learn from the Aviation Industry?
At the apex of the 1970s, the aviation industry found itself at the tail end of a 10-year path of negligence that culminated in the deaths of nearly 17,000 airline passengers worldwide. Amidst...
View ArticleWhat Barriers Exist to Quality Improvement in Healthcare?
The healthcare industry is boundless, encompassing a seemingly infinite network of organizations and individuals through a series of hospitals, doctors’ offices, specialists, manufacturers, and various...
View ArticleCan a Plan, Do, Study, Act (PDSA) Approach Work for Patient Safety Incidents?
Incidents in patient safety typically arise amidst several possible contributing factors and, without appropriate problem-solving strategies, can be exceedingly difficult to assess. Using process...
View ArticleLearning from Avoidable Harm and Death in Healthcare
In recent years, there has been an increasing recognition that the way in which the NHS investigates and learns from instances of avoidable harm and death is extremely variable and often poor. This is...
View ArticleDiagnostic Delays and Errors – Elephants in the Room
Diagnostic errors are ipso facto delays in arriving at an accurate diagnosis, often resulting in delays in appropriate therapeutic interventions and possibly resulting in harm. The reasons for...
View ArticleHow Do Human Factors Effect Decision Making in Healthcare?
Try as we might – despite our greatest efforts and accomplishments – humans have yet to create the perfect technology, one which subsists independently of human support and influence. We have developed...
View ArticleWhy Culture Matters – Supporting Quality Investigations for Learning
The environment in which healthcare services are provided is complex. This is confounded by numerous variables that impair the noble goals of achieving higher reliability and improving patient and...
View ArticleImproving Incident Investigations – Where there is a need, there must be a way!
There is an urgent need in health care that must be confronted. The latest studies regarding the deaths related to health care reveal that about 250,000 people die in the USA every year due to...
View ArticleWhat is a Just Culture?
To establish a just culture within the workplace is to foster a standard of accountability and trust that values learning over accusations. As businesses are comprised of humans, and humans are...
View ArticleHow organizations can learn from incident reporting
In cases of incident reporting, it’s easy to focus on mistakes and events that directly result in the harm or improper care of individuals. However, incidents often include factors such as minor...
View ArticleHow Big Data is improving healthcare
It’s easy to take data for granted. For many of us, data seems to simply materialize for our benefit. The methods by which data is collected is invisible to nearly all, save the individuals responsible...
View ArticleTraining + Mentoring + Personality = Leadership
Download this Article Are healthcare leaders born with the capacity to lead or a can anyone be trained to lead? It’s the old nature versus nurture debate, and the scientific underpinnings suggest that...
View ArticleMobile apps in healthcare
We live in an era of mobile technology. Everything we need to know, everything we want to purchase or browse or better understand is carried with us in our pockets. Whether bank account summaries,...
View ArticleWhy rigorous investigations matter
Advancements made in the healthcare industry over the years have been truly crucial in how we value and regard medicine. Technologies have been developed to perform surgeries and procedures not thought...
View Article“Lessons have been learned”
Whenever there is a story in the news about a serious NHS failure involving avoidable harm or death, the phrase ‘lessons have been learned’ is invariably included as part of the organisation’s media...
View ArticleWhy has root cause analysis not led to broad-based improvements in patient...
As its name would suggest, root cause analysis is the process by which teams of individuals assess and identify the underlying issues and factors that lead to unintended outcomes. In theory, root cause...
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