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

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 their 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. James Reason (2000) says this about system changes, “We cannot change the human condition, but we can change the conditions under which humans work.” It also starts to get at the sticky subject of blame in healthcare…

chi+med blog

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…

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