Why 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 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 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 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 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 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 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 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 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 Article“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...
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