‘My First Mistake’ reflections on handling a medical mistake & resources, from @drohanlon’s blog

We’ve recently linked to a couple of examples of wrong-site surgery that people involved with the surgery were kind enough to share publicly, in the hope that others can learn from them.

The post linked here also talks about a medical error. In this case a patient was discharged with too high a maintenance dose of warfarin resulting in them being readmitted a few days later having effectively taken an overdose.

‘My First Mistake’ is adapted from an e-learning session the author, Dr Shane O’Hanlon, runs at the University of Limerick. As such it’s quite detailed with further examples for reflection and links to resources.

My First Mistake by @drohanlon (30 October 2013)

Sharing errors can be a difficult thing to do and one of CHI+MED’s projects is Errordiary, a tool to enable people to share examples of everyday error.

Although the end result is very different the thought processes behind forgetting your keys or forgetting to give a patient medication are fairly similar so we can learn a lot about different types of errors from the everyday ones that are easier to share.

You can see examples of errors that have already been shared as well as some of the ways in which we’re using them, eg in teaching.

This entry was posted in case studies, health / medical, Human Factors, non CHI+MED, patient safety and tagged , , , , . Bookmark the permalink.

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