Wednesday, September 19, 2012

Wrong medical procedure a result of 'human error'

Irish Times by Fiona Gartland 19 September 2012

A CONSULTANT paediatrician who incorrectly recorded a procedure to be carried out on a 2½-year-old girl – who was later given the wrong operation – told a Medical Council fitness-to-practise committee yesterday the mistake was “human error”.

Prof Martin Corbally, who was a paediatric surgeon at Our Lady’s Children’s Hospital in Crumlin when the incident happened in 2010, said he was “probably quite tired” when he filled out the letter in question and accepted he made a mistake. But he said he had correctly recorded the procedure on the admissions card as “tongue tie upper frenulum” and administration had not completed the hospital booking system correctly because they omitted the words “upper frenulum”. “That is where the error really lay,” he said.

“I would see 80 to 100 patients a week between my three clinics and I was not really remembering their names,” he said. He also said he had “no way of knowing” the procedure that should have been carried out on Baby X when she attended for surgery weeks after he had seen her in outpatients.

If the procedure had been transcribed properly by administration he would have remembered, he said. He also said on the morning of the surgery he had been very busy and had three patients in intensive care.
He denied his instruction to his junior “to release the tongue tie” amounted to poor professional performance. There had been a series of errors in the case, he said.

“To err is human,” he said. “Everybody can make a mistake.” Prof Corbally said after the incident, procedures at the hospital had been improved. He also said he was “deeply concerned” about risk in surgery and had taken a course in risk management after the case involving the patient who had the wrong kidney removed. He had also carried out a study about parental involvement in medical staff meetings ahead of surgery on children.

In earlier evidence, an expert witness for the Medical Council, UK consultant paediatric surgeon Hugh Grant, from John Radcliffe Hospital, Oxford, said he believed the transcript error made by Prof Corbally amounted to poor professional performance and “started the chain of events” that led to the incident.
Under cross-examination from Eileen Barrington SC, for Prof Corbally, who queried whether a transcript error could be poor professional performance, Mr Grant said if you call a lump on the arm a lump on the leg you are applying your knowledge incorrectly which amounted to poor professional performance.

A Strategy for Human Factors/Ergonomics as a Discipline and Profession

ergoweb 19 September 2012. 

Peter Budnick refers to a paper from the Institute of Ergonomics and Human Factors (IEHF).  "In essence, the topic boils down to a few key questions, at least in my mind:
  • is there such thing as an ergonomics discipline or profession?
  • if so, what and who does it encompass?"
It is suggested their are four main reasons why Human Factors/Ergonomics (HFE) is under-utilized:
  1. many potential beneficiaries are not aware of the value HFE can bring;
  2. sometimes when there is a demand for HFE, there isn't enough "high-quality HFE," or that the available HFE resources are too limited in scope to be recognized as applicable;
  3. the HFE field is small in comparison to established design disciplines such as engineering and psychology, and though HFE principles may be applied within these disciplines, there may be no explicit reference to the HFE discipline.
  4. "... the very strength of HFE, its multi-disciplinary base, is also a potential weakness; a diversity of topics, views and practices exist within the HFE community, resulting in unclear communication to the external world."
 Key characteristics of HFE are identified as
  1. HFE takes a systems approach.
  2. HFE is design driven.
  3. HFE focuses on two related outcomes: performance and well-being.

The value of HFE for stakeholders
The committee recognizes that the demand for HFE is directly related to the perceived value of HFE among stakeholders of system design. They identify those stakeholders as (interested readers are directed to the full paper, cited below, for additional details):
  • System actors (employees in work-systems, and end-users for products and services) who can benefit from HFE through:
    • Improved physical, psychological and social well-being
    • Higher motivation, growth and job satisfaction 
    • Improved performance 
    • Better experience
    • Shorter time of familiarization
    • Better fitting of products/services to individual characteristics/needs
    • Fewer mistakes
    • Greater efficiency
  • System experts (any of a variety of professionals that can be involved in a design effort) who can benefit from HFE through:
    • Better users’ acceptance of designed systems
    • Better performance
    • Better fit with (legal) standards 
    • Improved development process 
  • System decision makers (e.g., managers, purchasers) who can benefit from HFE through:
    • Better productivity
    • Better quality and reliability of production processes and produced goods and services
    • Lower operating costs due to lower levels of health problems, motivational deficits, accidents, absenteeism, and related productivity loss
    • More innovation by increased employee creativity 
    • Better reputation for hiring and retention of talented employees
    • Better decision-making
    • Better market performance 
    • Greater profitability
    • Less re-design
  • System influencers who can benefit from HFE through:
    • Social wealth
    • Economic wealth