Beyond Error

Wears, Robert L.

doi:10.1111/j.1553-2712.2000.tb00457.x

Cited by 18 publications

(9 citation statements)

References 7 publications

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“…Observational studies can increase our understanding of complex problems and assist with generating hypotheses for future testing in rigorous evaluations [23]. However, observations in clinical practice can pose a challenge for researchers to capture all of the details relevant to a phenomena [24]. Video recording of the discharge communication process as it occurs in real time can produce a rich data set of both verbal and non-verbal communication behaviours, preserving the temporal and sequential structure that is critical for characterizing the interaction.…”

Section: Introductionmentioning

confidence: 99%

Understanding discharge communication behaviours in a pediatric emergency care context: a mixed methods observation study protocol

Curran

Bishop

Plint

et al. 2017

BMC Health Serv Res

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BackgroundOne of the most important transitions in the continuum of care for children is discharge to home. Optimal discharge communication between healthcare providers and caregivers (e.g., parents or other guardians) who present to the emergency department (ED) with their children is not well understood. The lack of policies and considerable variation in practice regarding discharge communication in pediatric EDs pose a quality and safety risk for children and their parents.MethodsThe aim of this mixed methods study is to better understand the process and structure of discharge communication in a pediatric ED context to contribute to the design and development of discharge communication interventions. We will use surveys, administrative data and real-time video observation to characterize discharge communication for six common illness presentations in a pediatric ED: (1) asthma, (2) bronchiolitis, (3) abdominal pain, (4) fever, (5) diarrhea and vomiting, and (6) minor head injury. Participants will be recruited from one of two urban pediatric EDs in Canada. Video recordings will be analyzed using Observer XT. We will use logistic regression to identify potential demographic and visit characteristic cofounders and multivariate logistic regression to examine association between verbal and non-verbal behaviours and parent recall and comprehension.DiscussionVideo recording of discharge communication will provide an opportunity to capture important data such as temporality, sequence and non-verbal behaviours that might influence the communication process. Given the importance of better characterizing discharge communication to identify potential barriers and enablers, we anticipate that the findings from this study will contribute to the development of more effective discharge communication policies and interventions.

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Section: Introductionmentioning

confidence: 99%

Understanding discharge communication behaviours in a pediatric emergency care context: a mixed methods observation study protocol

Curran

Bishop

Plint

et al. 2017

BMC Health Serv Res

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show abstract

“…In addition, less than three months before our incident, an affiliated teaching hospital put out an alert about three retained guidewire cases after CVC placement. The frequency of these incidents may not be attributable to inadequate training or the operator's lack of skill; rather, it may be due to the inevitability of human error [15]. Thus, to effectively attenuate adverse consequences due to human error, it is useful to critically examine and improve upon the deficiencies in the system itself [10].…”

Section: Discussionmentioning

confidence: 99%

A potentially hazardous complication during central venous catheterization: lost guidewire retained in the patient

Song¹,

Messerlian²,

Matevosian³

2012

Journal of Clinical Anesthesia

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“…10 Further, it is clearly established in the safety and human factors engineering literature that human error is inevitable, and systems that rely solely on the human component are bound to fail. 2,11 Experienced safety engineers in other settings (such as the aviation and nuclear industries) rely on multilayered design features as backup to prevent human error from having any effect on the system, or at least to mitigate the extent of deleterious human involvement.…”

Section: Discussionmentioning

confidence: 99%

Profiles in Patient Safety: Misplaced Femoral Line Guidewire and Multiple Failures to Detect the Foreign Body on Chest Radiography

Lum

Fairbanks

Pennington

et al. 2005

Academic Emergency Medicine

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This article uses a case report and discussion to demonstrate the concept of active and latent failures, and the "systems approach" to the reduction of adverse events in medicine. The case involves an inadvertently misplaced and retained guidewire during femoral vein catheterization using the Seldinger technique, and the subsequent failure to identify the guidewire in the chest despite several chest radiographs and a computed tomography (CT) scan read by radiologists, emergency physicians, and intensivists. This event reveals active failures in the performance of the Seldinger technique, latent failures in the design of the catheter kit, and problems with the current system of interpretation of radiographs. The authors conclude that the design of the catheter kit and the Seldinger technique should be critically examined from a human factors standpoint and that radiographic interpretation is still heavily subject to human error.

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Beyond Error

Cited by 18 publications

References 7 publications

Understanding discharge communication behaviours in a pediatric emergency care context: a mixed methods observation study protocol

Understanding discharge communication behaviours in a pediatric emergency care context: a mixed methods observation study protocol

A potentially hazardous complication during central venous catheterization: lost guidewire retained in the patient

Profiles in Patient Safety: Misplaced Femoral Line Guidewire and Multiple Failures to Detect the Foreign Body on Chest Radiography

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