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The national organisation Healthcare safety Investigation Branch (HSIB)
suggests
- The design of the swabs being used presently as a major issue.
Undue emphasis has been given to 'human error'.
Humans can make mistakes but after fall into 'error traps' made by poor design and unfavourable conditions .We present a solution that is 'Safer by design'
Donald Berwick an eminent patient safety specialist called for human errors
“to be made irrelevant to outcome, continually found and skillfully mitigated.”
He claimed that the answer is in “systems of work...the answer is in design.”
"Counting before and after" is a fallible system. If you have 52 cards in a deck, you will get them wrong at a predictable rate
and not realise it when you count them at different times." Atul Gawande - WHO Checklist Pioneer
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