Victorian Adult Burn Service, 55 Commercial Rd, Prahran, Victoria 3181: Y.Singer@alfred.org.au
Human error unfortunately is not a rare occurrence in all aspects of medicine, including burn care, and in recent years there has been a transformation in thinking and research about medical error and how to prevent them.
This new approach incorporates human factors and system engineering principles when dealing with adverse events. This approach moves away from the traditional style of medicine to seek out those who made mistakes, the “bad apples”, to one which focuses on improving the system. This approach makes it harder for people to make errors, and instead, makes it easier for people to do things right.
A human factors approach has been used in managing adverse events at the Victorian Adult Burn Service for two years. We approach human error as just the starting point of an investigation not the end point of understanding what happened.
A human factors approach to managing adverse events provides the best learning opportunities to help prevent errors occurring in the future. This presentation will use examples of errors which have occurred at our service and how human factors and system engineering have been used to help redesign the process of care to improve patient safety.
Adverse events: human error: patient safety
Yvonne Singer has worked in burn care for over 15 years and is the Program Coordinator of the Victorian Adult Burn Service in Melbourne, Australia. she is also the Vice President of the Australian & New Zealand Burn Association, and she loves all things burns!