Even doctors can make mistakes. It is part of human nature to be ridden with errors.
Safe design solutions can defend against human error and therefore improve patient safety.
We have engineered out two never events by considering human factors and using forcing functions that make the mistakes impossible, therefore transferring any blame to an institution that hasn’t employed the system, rather than the individual that has made the mistake.
Errors can be considered by either the person approach or the system approach. The person approach concentrates on the errors of the individual, saying they are somewhat inadequate for being inattentive or careless. This has the potential to develop a “blame culture” creating a fearful atmosphere for admitting to mistakes. This detrimental approach is likely to hinder development of safer healthcare systems.
Patient safety improvements rely on transparency within healthcare systems where lessons are learnt from discussing mistakes. The system approach is based on human errors being expected, but instead of blaming the individual, holds the system responsible. Developing effective system defenses to prevent errors are important in making never events a thing of the past.
Innovation 1: The WireSafe (Qualitech UK) prevents the guidewire retention never event, occurring in 1:3000 procedures and being the second commonest foreign object retention in the NHS.
The WireSafe has been designed by an NHS clinician and evaluated in an MD thesis at Cambridge University utilizing human factors science, by introducing a forcing function at the crucial point in the procedure.
Only the guidewire can be used to unlock the procedure pack by inserting it into a labeled hole, allowing access to the suture, suture holder, flush syringes and the antimicrobial dressing contained within the box.
This means that the guidewire must be removed from the patient to complete the central line procedure, therefore engineering out this never event. Following it’s use it doubles as a sharps disposal container for increased convenience and safety of staff.
The WireSafe received a Highly Commended Award at the National Patient Safety Awards 2016.
Innovation 2: The Needle free Non-Injectable Connector – NIC (Amdel Medical) prevents accidental arterial injection never events by utilizing a one way valve that only allows sampling not injection.
Additional benefits include preventing bacterial ingress into the arterial line hub, supporting the EU needle free directive and decreasing accidental blood spillage.
This innovation has won the AAGBI Innovation award (2015), the National Patient Safety Award (2012), was selected for the prestigious NHS Innovator Accelerator programme and has been personally recommended by Prof. Sir Bruce Keogh, Cardiac Surgeon and the Clinical Director of NHS England who stated “For the safety of our patients, I recommend this device should be used widely in the NHS”.
We have developed and tested innovations to engineer out the never event of guidewire retention and serious adverse event of accidental arterial injection. These allow leaders of institutions to mandate patient benefit, by making these never events, events that never occur again.