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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. 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
    2. 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
    3. 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
    4. 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
    5. 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
    6. 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

      1 reply 1 retweet 0 likes
    7. 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
    8. 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
    9. 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
    10. 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
      John Clarke‏ @C7RKY Oct 24
      Replying to @C7RKY @Cjw450Cathy and

      But take something like a surgical safety checklist, akin to a pre-flight checklist. If conducting those checks are designed to prevent wrong site surgery for example, surely it's right to regard someone who fails to complete one as having bypassed a known safety measure? No?

      3:31 AM - 24 Oct 2018
      1 reply 0 retweets 0 likes
        1. New conversation
        2. Cathy Welch‏ @Cjw450Cathy Oct 24
          Replying to @C7RKY @doctorcaldwell and

          No. Trying to find the latest article that explains why that is not always a valid argument...saw it a few days ago so hopefully can find it again quickly

          2 replies 1 retweet 1 like
        3. Cathy Welch‏ @Cjw450Cathy Oct 24
          Replying to @Cjw450Cathy @C7RKY and

          By following standards/policies/guidelines people think doing right things, but concentrate on beating the numbers or following the processes, stop thinking for themselves, and lose sight of the intended outcome- Liverpool Care Pathway one example, 4hr A&E targets another

          0 replies 0 retweets 0 likes
        4. End of conversation

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