0. Safe Prescribing and Prescription Errors Flashcards
What is considered in Reason’s Model of Error Causation?
The system and the individual. It also considers defences.
What are the primary components of Reason’s model or error causation?
Latent conditions, error producing conditions, and active failures.
What are latent conditions?
Processes inherent to an organisation or management decisions.
What are error producing conditions?
Poor environment or lack of communication.
What are active failures?
Errors of violations that an individual does.
What is a violation?
When an individual intentionally goes against others’ judgement or clinical guidelines.
What are the types of error? (Define each one briefly).
Mistakes - knowledge of rules based, slips - erroneous performance, lapses - erroneous memory.
What is the point of defences in the system?
Limit the chances of error occurring.
What is the Swiss Cheese model?
Defences put in place are imperfect so allow holes in the layers to develop. More defences means more layers of cheese and less likely chance that the holes line up and an error can pass through.
