Health and safety abstracts

Citation

(2003), "Health and safety abstracts", Measuring Business Excellence, Vol. 7 No. 4. https://doi.org/10.1108/mbe.2003.26707dab.011

Health and safety abstracts

A look into the nature and causes of human errors in the intensive care unitDonchin, Y., Gopher, D., Olin, M., Badihi, Y., Biesky, M., Sprung, C.L., Pizov, R. and Cotev, S., Quality and Safety in Health Care (UK), April 2003, Vol. 12 No. 2, Start page: 143, No. of pages: 6

Features a study that investigates the nature and causes of human errors in a medical-surgical hospital intensive care unit (ICU); describes the development of a methodology to avoid or reduce error frequency and impact (defines human error as a deviation from standard conduct). Outlines the error reporting system; refers to the 46 patients included in an observation study; records the data collection that indicated there was 544 human errors (table included). Puts forward the way in which the study served as a model for examining the applicability of concepts and task analysis methods to the study of medical teams; highlights the importance of good communication between physicians and nurses. Spells out the major problems that were demonstrated in the analysis of the ICT; concludes that human factors engineering proved to be beneficial and powerful in the analysis of human errors in the ICT (includes commentary).

Human factors engineering design demonstrations can enlighten your RCA teamGosbee, J. and Anderson, T., Quality and Safety in Health Care (UK), April 2003, Vol. 12 No. 2, Start page: 119, No. of pages: 3

Highlights how root cause analysis is sometimes applied in a way that focuses on policy violation issues, and personal shortcomings, rather than on underlying design factors. Presents a case study of an adverse event that happened during surgery at a US hospital; describes how a root cause analysis team was formed to develop a chronological flow chart of events; records the way in which the team focused on the personal shortcoming and policy inadequacies rather than on design faults. Outlines how the hospital's patient safety manager applied human factors engineering to the situation, and re-directed the teams attention to design issues, and to re-adopting a systems-orientated perspective.

And all who jumped died: the triangle shirtwaist factory firePence, P.L., Carson, P.P., Carson, K.D., Hamilton, J.B. and Birkenmeier, B., Management Decision (UK), 2003, Vol. 41 No. 4, Start page: 407, No. of pages: 15

Describes how the Triangle Shirtwaist Factory Fire in New York City (25 March 1911) was the instigation for a raft of major employee protection legislation; looks at the events of that day and outlines the response of the factory owners' to the fire; spells out the legislation initiated, during the New Deal era, as a direct result of the fire. Discusses whether the owners of the factory were bad people or good people spoiled in a bad environment; highlights how many of the actions were unethical but lawful at the time of the event; concludes by drawing some lessons from the research.

The culture of safety: results of an organization-wide survey in 15 California hospitalsSinger, S.J., Gaba, D.M., Geppert, J.J., Sinaiko, A.D., Howard, S.K. and Park, K.C., Quality and Safety in Health Care (UK), April 2003, Vol. 12 No. 2, Start page: 112, No. of pages: 7

Details a safety culture survey carried out in the USA; identifies its two principal objectives as being to measure attitudes towards patient safety, and organizational culture, in 15 hospitals that participated in the California Patient Safety Consortium, and to determine how the culture of safety varied among the hospitals and between the different types of healthcare personnel. Sets out to measure the level of problematic responses from the questionnaire that would indicate that the hospital failed to meet the criteria of being a high reliability organization. Describes the 16-topic survey instrument employed in the study; outlines the analysis of the responses to questions by respondent hospital, job class and clinician status. Presents the findings indicating, among other things, that there was a definite discrepancy between the attitudes of senior managers and those of non-managers; highlights the implications of the study; urges further research.

Developing a departmental culture for reporting adverse incidentsBhatia, R., Blackshaw, G.R.J.C., Rogers, A., Grant, A. and Kilkarni, R., International Journal of Health Care Quality Assurance (UK), 2003, Vol. 16 No. 3, Start page: 154, No. of pages: 3

Features a study that developed a simple model for reporting critical incidents and near misses within a UK hospital orthopedic department; describes the use of forms to record incidents (technical and organizational) by medical staff. Records the 64 critical incidents and near misses reported; outlines the use of monthly multidisciplinary clinical governance meetings to discuss all incidents; highlights the benefits of the program; puts forward how it has, among other things, heightened awareness of good practice in the department.