Change the System, not the people: Neil Spenceley at DFTB19

Cite this article as:
Team DFTB. Change the System, not the people: Neil Spenceley at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22275

Neil Spenceley is a paediatric intensivist and is the National Lead for Paediatric Patient Safety.

This talk is packed with nuggets that will change the way you view the world in which you practice. Neil explains Safety 1 and Safety 2 thinking. The talk is wide-ranging and covers poor behaviours in healthcare both at a personal level and at an institutional level.

If you just want to read one key paper to get you started then read this one from paediatric surgeon, Lucian Leape.

Leape LL. Error in medicine. Jama. 1994 Dec 21;272(23):1851-7.

If you want to read two papers (and we suggest you should) then download this one too.

Hollnagel E. Human error. InPosition paper for NATO conference on human error 1983 Aug.

 

 

 

Doodle medicine sketch by @char_durand 

 

©Ian Summers

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Selected References

 
Cook RI, Nemeth CP. “Those found responsible have been sacked”: some observations on the usefulness of error. Cognition, Technology & Work. 2010 Jun 1;12(2):87-93.
 
Katz D, Blasius K, Isaak R, Lipps J, Kushelev M, Goldberg A, Fastman J, Marsh B, DeMaria S. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ quality & safety. 2019 May 31:bmjqs-2019.
 
Kellogg KM, Hettinger Z, Shah M, Wears RL, Sellers CR, Squires M, Fairbanks RJ. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?. BMJ Qual Saf. 2017 May 1;26(5):381-7.
 
Hollnagel E, Amalberti R. The emperor’s new clothes: Or whatever happened to “human error”. InProceedings of the 4th international workshop on human error, safety and systems development 2001 Jun 11 (pp. 1-18). Linköping University.
 
Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf. 2017 May 1;26(5):417-22.
 
Wu AW. Medical error: the second victim: the doctor who makes the mistake needs help too. BMJ Online 2000

Bubble Wrap Live – Top 5 papers in Gen Paeds: Susie Piper at DFTB19

Cite this article as:
Team DFTB. Bubble Wrap Live – Top 5 papers in Gen Paeds: Susie Piper at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22018

In the three years since we launched the Bubble Wrap segment we have been able to highlight a number of key articles in paediatric research.  In this talk from the popular Bubble Wrap Live! sessions, Susie Piper brought us her top five favourite articles from the general paediatrics realm.

 

Here are the five* articles Susie chose.

Freedman SB, Williamson-Urquhart S, Farion KJ, Gouin S, Willan AR, Poonai N, Hurley K, Sherman PM, Finkelstein Y, Lee BE, Pang XL. Multicenter trial of a combination probiotic for children with gastroenteritis. New England Journal of Medicine. 2018 Nov 22;379(21):2015-26.
 
Schnadower D, Tarr PI, Casper TC, Gorelick MH, Dean MJ, O’Connell KJ, Mahajan P, Chun TH, Bhatt SR, Roskind CG, Powell EC. Randomised controlled trial of Lactobacillus rhamnosus (LGG) versus placebo in children presenting to the emergency department with acute gastroenteritis: the PECARN probiotic study protocol. BMJ open. 2017 Nov 1;7(9):e018115.
 
Murata S, Okasora K, Tanabe T, Ogino M, Yamazaki S, Oba C, Syabana K, Nomura S, Shirasu A, Inoue K, Kashiwagi M. Acetaminophen and febrile seizure recurrences during the same fever episode. Pediatrics. 2018 Nov 1;142(5):e20181009.
 
Manley BJ, Arnolda GR, Wright IM, Owen LS, Foster JP, Huang L, Roberts CT, Clark TL, Fan WQ, Fang AY, Marshall IR. Nasal high-flow therapy for newborn infants in special care nurseries. New England Journal of Medicine. 2019 May 23;380(21):2031-40.
 
Tagg A, Roland D, Leo GS, Knight K, Goldstein H, Davis T, Don’t Forget The Bubbles. Everything is awesome: Don’t forget the Lego. Journal of paediatrics and child health. 2018 Nov 22.
 
Riskin A, Erez A, Foulk TA, Kugelman A, Gover A, Shoris I, Riskin KS, Bamberger PA. The impact of rudeness on medical team performance: a randomized trial. Pediatrics. 2015 Sep 1;136(3):487-95.
 
*The astute amongst you might have noticed the inclusion of six trials rather than five. Susie decided to combine the two probiotic trials.

 

DoodleMedicine interpretation by @char_durand – completed in real time from Australia via the DFTB19 livestream 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button