I brought-up Bob when explaining to my colleagues the meaning of ‘happy accident’ – I was being flippant although the context was not.
I wonder What is the rule for hospital Inpatient falls. I mean, There must be some Golden Rule That you can Work-out. How many minor falls For every bad fall. Bad being Broken hip, Brain bleed Death. Interesting ratio to calculate. ‘How many patients have fallen in your hospital inContinue reading “Falls (Swiss cheese and serious harm)”
They say* That clinical error is like Swiss Cheese; You line-up the holes, twist and turn through happenstance and bad luck and eventually If you are lucky You survive. And, if you’re not, the allergy is missed and the check and the dispense and the doctor and the nurse and the pharmacist are allContinue reading “Swiss Cheese”
On Friday I attended the Yorkshire and Humber Patient Safety Collaborative ‘One Year On’ conference. A number of speakers from the region discussed the work they are doing to make predominantly hospitals, but all care in the wider sense, safer, less likely to result in inadvertent harm. Primum non nocere – first, do no harm,Continue reading “Human Factors, space-time and Yiddishkeit”