Near misses and medical error – how a systems approach can change safety culture (short video)

Annie’s Story: How A Systems Approach Can Change Safety Culture
from MedStar Health.

Here’s a short video that nicely illustrates how a systems approach can be more effective in improving patient safety.

A patient’s blood glucose level was actually extremely low but the blood glucose meter the nurse was reading indicated the exact opposite. To try and bring the ‘high’ level down the nurse gave the patient some insulin, which of course just lowered it further. The patient became unresponsive and was taken to intensive care where the problem was spotted – fortunately both the patient and their blood glucose levels recovered.

When a second nurse experienced a similar problem with a blood glucose meter the initial response resulted in one of the nurses being placed under a disciplinary investigation with threat of suspension. This shook the nurse’s confidence, yet didn’t seem to solve the problem.

Hospital staff asked a human factors engineering team to evaluate the processes involved in the error and its knock-on effects. It became clear that design issues might have contributed to the problem and the team looked at identifying some of the system factors that also may have led to the problem.

Another positive outcome of the hospital recognising that there was more to the story than simply attributing blame to the nurse was that the disciplinary threat against her was removed – this sent a very positive message to colleagues that the hospital’s senior management were more interested in a ‘just culture’ than a ‘blame culture’ and that people should be encouraged to report the near misses and not just wait until something goes wrong.

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

One Response to Near misses and medical error – how a systems approach can change safety culture (short video)

  1. domfurniss says:

    Reblogged this on domfurniss and commented:
    This video explains the sort of research I have been involved in and why: it highlights that relatively small errors in medical device design can have big consequences; in terms of psychology people quickly piece together signals from their environment with expectations, the default position seems to be suspend and investigate individuals rather than look at the arrangement and design of the broader system in which they work. “We cannot change the human condition, but we can change the conditions under which humans work” (Reason, 2000).

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