New strategies may cut screening errors

A study in Current Biology has found a possible way to cut the number of mistakes made by medical staff looking for breast and cervical cancers. US researchers found that the time spent and errors made made during a visual search for target items in X-ray images varied according to the chances of finding the target.

"If you are trying to find 20 cases of breast cancer from 40 mammograms, you'll find more of them than if you look for the same 20 cases from 2,000 mammograms", said lead author, Jeremy Wolfe of Harvard Medical School. 

The authors say that doing a booster exercise before starting work helps them to visualise what they are looking for and improves their search success rate in the subsequent session. 

Richard Evans, Chief Executive of the Society of Radiographers said: "I look forward to seeing more details about this research, but radiographers would welcome techniques which help ensure the best possible standards." He pointed out that the NHS already monitors the performance of everyone involved in breast screening through a regular audit. Source: BBC, 16 January, 2010. tinyurl.com/yg4mson

NHS faces 'potentially serious problems' from wrong prescriptions

The Telegraph reports on the problems faced by junior doctors, who fill out five or six prescription forms on average during their  time in medical school only to have to complete dozens on their first day on the wards. The inadequate preparation contributes to errors that could harm patients - such as omitting drugs, wrong doses, not taking account of a patient's allergies, illegible handwriting or ambiguous orders. According to the General Medical Council 10 per cent of all prescriptions issued by doctors contained such errors. 

Now the British Pharmacological Society (BPS) is calling for an exam for medical students and a "prescribing simulator" complete with virtual patients to be introduced to the curriculum so that medics are better prepared when they start in hospitals. Professor Simon Maxwell, chairman of the BPS, said: "We would not accept this kind of error rate in other industries such as aviation. It is a recipe for problems." Source: Telegraph, 15 December, 2009. tinyurl.com/ybnvpnx

Nearly one in 10 prescriptions has mistakes

Nearly one in 10 hospital prescriptions contains a mistake, ranging from the minor to the potentially lethal, according to research commissioned by the General Medical Council. However, very few errors would have caused serious harm. The research team, led by Professor Tim Dornan of the University of Manchester, examined the issue amid rising fears inexperienced doctors were making prescription errors which could, at worst, result in a patient dying. 

The team examined 124,260 prescriptions across 19 hospitals - and found just under 9% contained errors. Of these 11,077 errors, overwhelmingly intercepted and corrected before reaching the patient, about 2% contained potentially lethal instructions - such as failing to take account of a patient's allergies. More than half involved errors in which a patient's medication was not prescribed and 40% were involved illegible or ambiguous prescriptions.

Very few of these mistakes caused actual harm to a patient because on the whole they were stopped by senior doctors, nurses - and in particular pharmacists. But the study did not find doctors fresh out of medical school were making the most mistakes - as has often been suggested,

"The research shows the complexity of the circumstances in which errors occur and argues against education as a single quick-fix solution”, said Professor Dornan. However, the GMC is calling for a UK-wide standard prescription chart as exists in Wales. Support for the idea is provided by Professor Peter Rubin (chairman of the GMC), Dr Hamish Meldrum (British Medical Association), and Joyce Robins (Co-Director of Patient Concern). A Department of Health spokesman said it would continue to look into the benefits of electronic prescribing system. 

However, Professor Simon Maxwell, of the British Pharmacological Society said he was “dismayed at the suggestion that improved education and training is not a central part of the solution. There is plenty of evidence from around the world to show that when appropriate education and training are delivered, prescribing improves." Source: BBC, 3 December 2009. http://tinyurl.com/ydfbepb

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Passenger accidentally activates ejector seat

The Telegraph report a story on a tricky and not uncommon design problem - that of a safety-critical control that needs to be very quick and easy to access, without it ever being activated acidentally. A novice aviator took off for a joyride with an experienced pilot from South Africa's Silver Falcons air display team, and got a free parachute ride. During an aerobatic manoeuvre, the flier accidentally pulled on the black and yellow emergency handle between his legs, activating two rockets attached to the back of the seat. The seat and occupant were sent through the jet's perspex canopy and 100 metres into the sky. The lever is fitted as standard in the Pilatus PC-7 Mk II jets. The man floated back down to Earth on a parachute as the South African Airforce bosses scrambled a helicopter to pick up the passenger near Langebaanweg airfield, 80 miles north of Cape Town. Source: Telegraph, 1 November 2009. tinyurl.com/yk76k95

No cure for IVF errors

The chairman of the British Fertility Society has warned that IVF mix-ups, in which women are given someone else's embryo, will continue to happen. Recently a couple were told that their last frozen embryo had been mistakenly implanted into another patient. The woman went on to have a termination after being was told that she had been inseminated with a child that was not her own. A trainee embryologist was said to have taken the embryo from the wrong shelf at the IVF clinic, based at the University Hospital of Wales. The Human Fertilisation and Embryology Authority (HFEA) already requires a system of "double witnessing" in which staff check and document each other's work, to reduce the risk of such mistakes. But the case has led to calls that embryos should be electronically "tagged" to prevent mix-ups ever happening again. Mr Rutherford said: "Everybody working in this field wants to avoid a mix up... but we do live in the real world and unfortunately when humans are involved there will be mistakes. But the risks are incredibly small". According to the Telegraph, some centres are reportedly experimenting with an electronic system, involving bar codes and alarms, to replace "double witnessing". But Mr Rutherford said that there were no guarantees that they would be any more successful than the current system. Source: Telegraph, 26 June 2009. tinyurl.com/km2uov

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From input error to near disaster at Melbourne airport

An Emirates flight EK-407 from Melbourne to Dubai narrowly avoided disaster, with 275 people on the Airbus jet. On the flight deck, the first officer and the captain fed routine information, including the plane's weight and fuel load, into a computer. The procedure was for them to check each other's work to avoid mistakes. The first officer opened the throttles and headed down runway. As the first officer tried to ease the aircraft off the runway, the jet stayed grounded. On a second attempt, the nose came up — but the jet's rear repeatedly hit and dragged along runway, puncturing the skin of the jet, tearing off a panel and breaching the air pressurisation. Eventually, at the end of the runway, the jet began climbing. But it was still too low, hitting a runway light, then antenna equipment on the ground, and scraping the grass. With seconds to spare, the jet climbed and finally reached a safe height. The pilots dumped most of their fuel over the bay and, with smoke in the cabin, the plane was given emergency clearance to land. When the pilots checked their instruments they spotted the potentially fatal mistake. Before take-off, their fuelled-up jet weighed 362 tonnes. But they had accidentally keyed in 262 tonnes, resulting in too little engine power. Only the captain's rapid reactions averted a disaster. Source: Sydney Morning Herald, 01 May 2009. tinyurl.com/kjd3r2
Image: http://www.flickr.com/photos/storm-crypt/ / CC BY-NC-ND 2.0

Have you forgotten your memory stick?

A report into the loss of a memory stick containing data on 6,360 prisoners and ex-prisoners found – predictably – that human error and procedural violation was to blame. The USB stick was being used to back up clinical databases at HMP Preston and was lost on 30 December. The data lost was encrypted but, in a classic example of how IT security actually causes users to bypass defences, the password had been written on a note attached to the misplaced memory stick. Source: BBC, 17 April 2009. tinyurl.com/dl3ceu
Image: http://www.flickr.com/photos/zlatanm/ / CC BY-NC-ND 2.0.

Intensive care errors ‘frequent’

Errors in the administration of injected medication occur frequently in intensive care units, a study of 113 units across 27 countries suggests. Over a 24-hour period, 441 patients out of 1,300 were subject to errors, and seven suffered permanent harm. Nearly half of the affected patients suffered more than one mistake. The most frequent errors related to the wrong time of administration and missing doses. Stress, tiredness, recent changes in the drug’s name, poor communication, and protocol violations were cited as contributing factors. Lead researcher Dr Andreas Valentin recommended error reporting systems and routine checks at shift changes. The Intensive Care Society said many units had developed patient safety training programmes, including measures to learn from ‘near misses’. Work was also under way to standardise concentrations of some drugs for critically ill patients, refine the use of antibiotics and minimise the risk of adverse drug reactions. Source: BBC, 13 March 2009. http://tinyurl.com/b9cqz6

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All sites may harm your computer

The world's dependency on Google was brought into focus on Saturday, 31 January when users were unable to access search results, as the entire internet was erroneously flagged as malware. For a period, all results brought with them the warning that the site "may harm your computer", and advice to choose another hit. "What happened? Very simply, human error," wrote Marissa Mayer, Google vice president search products and user experience, on the Official Google Blog. When Google updated the list on in conjunction with stopbadware.org, it mistakenly flagged all sites as potentially dangerous. Source: BBC. http://tinyurl.com/bm8ahx

When one letter makes a big difference

Traveller Samantha Lazzaris was planning a holiday in San José, Costa Rica, filled with yoga, meditation, hiking and voluntary work. She ended up in San Juan, Peurto Rico. Waiting outside the airport, she asked the taxi driver to take her to her hotel, giving him an address in San José, Costa Rica. “He looked in amazement, speechless,” she said. “Then [he] laughed and said, ‘This is not Costa Rica. It’s Puerto Rico’.”’ How did it happen? Apparently, the Bristol branch of Thomas Cook had entered the wrong code. Both similar sounding places, with even more similar sounding, and looking, codes - SJO (San José) and SJU (San Juan). To make matters worse, San Jose is also known as Juan Santamaria. According to The Times, tourists looking forward to a trip to San José had also found themselves in San José, California. La Paz, Bolivia gets confused with La Paz, Mexico, and Santiago in Chile gets confused with San Diego, in southern California. Source: Times, 11 February 2009. http://tinyurl.com/c83vou

Image: http://www.flickr.com/photos/wallyg/ / CC BY-NC-ND 2.0