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C7RKY's profile
John Clarke
John Clarke
John Clarke
@C7RKY

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John Clarke

@C7RKY

Of course views all mine. All without prejudice. Just a regular chap after all. Oh...and RT's may equally imply ridicule as endorsement.

UK
Joined December 2011

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    1. Ken Lownds‏ @KenZeroHarm Oct 23
      Replying to @doctorcaldwell @pkakodkar001 and

      ZHH you were asking about a definition of Avoidable Harm, Gordon?

      1 reply 0 retweets 0 likes
    2. Dr Gordon Caldwell‏ @doctorcaldwell Oct 23
      Replying to @KenZeroHarm @pkakodkar001 and

      Avoidable Death

      1 reply 1 retweet 0 likes
    3. Ken Lownds‏ @KenZeroHarm Oct 23
      Replying to @doctorcaldwell @pkakodkar001 and

      ZHH Both? You have your developed some definitions?

      1 reply 0 retweets 0 likes
    4. Dr Gordon Caldwell‏ @doctorcaldwell Oct 23
      Replying to @KenZeroHarm @pkakodkar001 and

      No

      2 replies 1 retweet 0 likes
    5. Cathy Welch‏ @Cjw450Cathy Oct 23
      Replying to @doctorcaldwell @KenZeroHarm and

      Gordon, can you elaborate on why you haven’t defined any deaths as ‘Avoidable’ in the reviews you have done? Is it the term? The lack of definition? Or another factor?

      1 reply 0 retweets 0 likes
    6. Prashant Kakodkar‏ @pkakodkar001 Oct 23
      Replying to @Cjw450Cathy @doctorcaldwell and

      It is possible to identify care that could have been better (although with hindsight bias) - but this can only be confidently seen as an association. Causation is very difficult to attribute in most cases. Learning comes from how we can improve care & not from definition IMV.

      1 reply 0 retweets 1 like
    7. Cathy Welch‏ @Cjw450Cathy Oct 23
      Replying to @pkakodkar001 @doctorcaldwell and

      Awareness of hindsight bias, limitations of ‘causation’ very important. How can ensure appropriate training and interpretation? as could easily be used as another tool of diversion and blame

      1 reply 1 retweet 0 likes
    8. Prashant Kakodkar‏ @pkakodkar001 Oct 23
      Replying to @Cjw450Cathy @doctorcaldwell and

      If I understand you rightly you are saying ‘never events’ ‘ZHH’ are nirvana. The data will perhaps unfortunately prove you right - may be for decades. If we aspire for something big than not we are more likely to have a greater impact on reducing harm suffered in healthcare.

      3 replies 1 retweet 0 likes
    9. Cathy Welch‏ @Cjw450Cathy Oct 24
      Replying to @pkakodkar001 @doctorcaldwell and

      There is a lot of background and reasoning to why ‘zero’ is a false panacea, and potentially harmful in itself, from wider Safety work in other industries... a great introductory video, lots to make you think...https://youtu.be/moh4QN4IAPg 

      3 replies 1 retweet 1 like
    10. Dr Gordon Caldwell‏ @doctorcaldwell Oct 24
      Replying to @Cjw450Cathy @pkakodkar001 and

      Like Never Events are generally an unhelpful concept ...

      1 reply 0 retweets 2 likes
      John Clarke‏ @C7RKY Oct 24
      Replying to @doctorcaldwell @Cjw450Cathy and

      I think it's been watered down by the list growing from the original 7, but the concept had merit for me. It's not to suggest that the event will never happen, but that the event *should* never happen. So if it does, somebody bypassed a known safety measure designed to prevent it

      3:01 AM - 24 Oct 2018
      • 1 Retweet
      • paul jackman
      1 reply 1 retweet 0 likes
        1. New conversation
        2. Cathy Welch‏ @Cjw450Cathy Oct 24
          Replying to @C7RKY @doctorcaldwell and

          That’s where problems lie, John. There may not be pre-existing ‘safety measure’, or may not be most appropriate in that particular circumstance. It may have been produced/implemented by people who aren’t actually doing job, and not be fully aware of realities at sharp end.

          1 reply 0 retweets 0 likes
        3. Cathy Welch‏ @Cjw450Cathy Oct 24
          Replying to @Cjw450Cathy @C7RKY and

          And that‘s typical thought process that leads to blame culture, whether we expect it to or not, by nature of thought process, as you said yourself...”So if it does, somebody bypassed a known safety measure designed to prevent it”

          1 reply 0 retweets 0 likes
        4. Cathy Welch‏ @Cjw450Cathy Oct 24
          Replying to @Cjw450Cathy @C7RKY and

          Look far enough, always ends up blaming individual. But what if the ‘Safety measure’ was faulty, inappropriate, misapplied, hidden away in some obscure location? Individual still gets blamed for not adhering to it. Nothing changes, no winners, only losers all round

          1 reply 0 retweets 0 likes
        5. John Clarke‏ @C7RKY Oct 24
          Replying to @Cjw450Cathy @doctorcaldwell and

          Woah.. blame is a whole different conversation. That's where the circumstances of why something happened get explored. But it should not alter defining what happened as a known safety measure being bypassed. If the measure is faulty/inappropriate then doesn't fit the definition.

          2 replies 0 retweets 0 likes
        6. Cathy Welch‏ @Cjw450Cathy Oct 24
          Replying to @C7RKY @doctorcaldwell and

          But, if I had not raised it, would you have questioned the validity of the ‘Safety measure’ before stating causation? I fear not. Few do

          1 reply 0 retweets 0 likes
        7. John Clarke‏ @C7RKY Oct 24
          Replying to @Cjw450Cathy @doctorcaldwell and

          I hinted at it when I mentioned the 'watering down' of the list, so yes, I do have questions on some now. But number 1 on the list of Never Events since it began has always been wrong site surgery. And I can understand how a surgical safety checklist can prevent that, if used.

          1 reply 0 retweets 0 likes
        8. Cathy Welch‏ @Cjw450Cathy Oct 24
          Replying to @C7RKY @doctorcaldwell and

          But as important as Checklist is culture/communication in team, shared understanding, mutual respect. Checklist ‘forces’ some ideals, but also forces teams to work in ways not always best in real situations➡️shortcuts taken, distractions happen BECAUSE of checklists, not despite

          1 reply 0 retweets 0 likes
        9. John Clarke‏ @C7RKY Oct 24
          Replying to @Cjw450Cathy @doctorcaldwell and

          Imagine you're going on holiday. Somewhere hot (for a change). As you're boarding the flight you overhear the pilots expressing a similar view about the pre-flight checklist. Would you still take your seat, happy to let them decide whether it's best to do the checklist or not?

          1 reply 0 retweets 0 likes
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