Improving patient safety by instructional systems design

Improving patient safety by improving medication communication.

Any time that information about a patient's medication is communicated, there is a potential for error that occurs because of misinterpretation of abbreviations, acronyms, and dose designations. In the following discussion, corrective approaches for reducing the use of error-prone terms will be reviewed. Terms on the "Do Not Use" list are identified and the rationale for using "Tall Man" letter...

Potential for improving patient safety by computerized decision support systems.

General Practice, as the point of first contact with the health care system, is characterized by a wide range of potential diagnoses, relatively unstructured presentations and a low prevalence of serious morbidity. Although this may seem a benign environment for patient safety, the sheer volume of episodes, 90% of contacts in many health care systems, mean that only very low risks can be tolera...

Improving patient safety by design -- a new spinal/intrathecal injection safety system.

readily be achieved with the inverted insertion (i.e., with the concave surface facing backward) of a polyvinyl chloride endotracheal tube.2 They attributed their success, in part, to the more anatomic direction of the tube on emergence from the Fastrach laryngeal mask airway with the inverted tube insertion technique. A similar “hang up” is often seen during tracheal intubation using the Bulla...

Patient safety, systems design and ergonomics.

The complexity of the health care environments necessitates an holistic and systematic ergonomics approach to understand the potential for accidents and errors to occur. The health service is also a socio-technical system, and design needs must be met within this context. This paper aims to present the design challenges and emphasises the specialised needs of the health care sector, when dealin...

Improving patient safety.