A review of patient safety incidents reported as ‘severe’ or ‘death’ from critical care units in England and Wales between 2004 and 2014

Thomas, Antony; Macdonald, John

doi:10.1111/anae.13547

Cited by 17 publications

(21 citation statements)

References 17 publications

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“…Using this model, a substantial amount of effort has been devoted to examining the sequence of events leading up to accidents to try to understand how the accident came about and thus help to prevent recurrence. This approach was adopted in aviation and subsequently in healthcare, in the NHS and especially in anaesthesia . A typical approach is depicted in Fig.…”

Section: The Three ‘Ages’ Of Safetymentioning

confidence: 99%

People, systems and safety: resilience and excellence in healthcare practice

Smith

Plunkett

2018

Anaesthesia

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Summary This article outlines recent developments in safety science. It describes the progression of three ‘ages’ of safety, namely the ‘age of technology’, the ‘age of human factors’ and the ‘age of safety management’. Safety science outside healthcare is moving from an approach focused on the analysis and management of error (‘Safety‐1’) to one which also aims to understand the inherent properties of safety systems that usually prevent accidents from occurring (‘Safety‐2’). A key factor in the understanding of safety within organisations relates to the distinction between ‘work as imagined’ and ‘work as done’. ‘Work as imagined’ assumes that if the correct standard procedures are followed, safety will follow as a matter of course. However, staff at the ‘sharp end’ of organisations know that to create safety in their work, variability is not only desirable but essential. This positive adaptability within systems that allows good outcomes in the presence of both favourable and adverse conditions is termed resilience. We argue that clinical and organisational work can be made safer, not only by addressing negative outcomes, but also by fostering excellence and promoting resilience. We outline conceptual and investigative approaches for achieving this that include ‘appreciative inquiry’, ‘positive deviance’ and excellence reporting.

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Section: The Three ‘Ages’ Of Safetymentioning

confidence: 99%

People, systems and safety: resilience and excellence in healthcare practice

Smith

Plunkett

2018

Anaesthesia

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“…One reason is that some research questions simply cannot be tackled using the randomised controlled format . There is also much to gain from analyses, for instance of routinely‐collected data, as these can make initial sense of what is held, help establish trends and formulate hypotheses for further testing . We should also remember that the systematic review, much vaunted as the highest level of clinical research evidence, has a retrospective character too.…”

Section: Retrospective Studiesmentioning

confidence: 99%

Major trauma and the need for massive transfusion

Smith

Choi

2017

Anaesthesia

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“…Nasogastric tube (NGT) insertion is common in the intensive care unit for enteral feeding. However, it is not without procedural complications, including epistaxis and even oesophageal perforation , and severe patient safety incidents have been reported . We recently experienced a case of polyurethane NGT rupture using the new Enfit™ (CORPAK MedSystems, Inc., USA) safety system .…”

mentioning

confidence: 99%