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The training started with 4 h of interactive seminars concerning safe teamwork during times of stress, in which the main learning objectives were knowledge and understanding of safety in complex organisations, errors due to human fallibility in a stressful environment that can be avoided and safety tools for stress management.
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Reports summarising medication incidents (e.g. administration errors) were generated from the organisation's incident reporting system.
These occur as a result of the association of human, individual or collective errors, with latent or system errors, all relating to the organisation and structure of care units [ 59].
World-class organisations interrogate errors, learn from them, and only blame after they have found out what happened.
The review - by a leading surgeon and hospital boss - called for a statutory duty of candour on hospitals, GPs and other organisations when errors were made that caused significant harm.
The National Patient Safety Agency NPSAA) feedback report for the Norfolk and Norwich Hospital shows that, compared with similar organisations, medication error reporting is low.
The findings regarding postgraduate trainees are consistent with the report in the UK where 66% of junior doctors understood the role of healthcare organisations in error management.
Organisations that sweep errors under the carpet do not learn lessons.
Healthcare organisations often learn from errors in the use of local and national reporting systems.
"While no organisation is immune from errors, it has become apparent recently that a very serious error was made in dealing with Mr Downey's case, which is a matter I regret very deeply.
8 10 While personal factors such as forgetfulness, inattention, poor motivation, carelessness, negligence and recklessness are important, a health systems approach more comprehensively addresses recurrent errors and organisation factors and processes which may give rise to that error.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com