Adverse events Flashcards
What is system error?
Mistakes made in patient treatment that occur due to:
The environment for working being understaffed, lack of resources, time constraints, poor team communication
Culture of the environment
Management leadership style
Why do system errors occur?
These occur due to
—> Active failure by those in direct contact with the patient/system, which is hard to foresee.
—> Latent conditions, as a result of decisions from top management and designers, which include error-provoking conditions like time-constraints and understaffing. These combined with active failure can lead to an error, however latent conditions can be mitigated.
What is individual error?
Mistakes due to human factors like forgetfulness, inattention or malintent like negligence and recklessness.
What are the causes for adverse events in maternity care?
Medication errors
Organisation issues
Inadequate maternal birth position
Peripartum therapy delay
Diagnostic errors
What is adverse error?
Unintended event from clinical care which causes patient harm.
What is a near miss?
Events or omissions arising during clinical care fail to develop further but have potential for injury to patient.
How can patient safety be improved?
Increase nurse and doctor ratio
Patient safety culture where open reporting and teamwork occurs
Hand hygeine
Standardise approaches to high risk patients
Promote safer prescribing
Early recognition of deteriorating aptients
What is a never event?
Serious preventable incidents, where guidance and safety recommendations are strong barriers to occurrence at a national level, which should be implemented by all healthcare providers.
What are the causes of adverse events?
This occurs due to issues with:
—>management communication/leadership
—> background factors such as workload
—> lack of knowledge/ working beyond competency
—>misapplication of a rule
—> distractions during working causes prescribing error
—> Unsafe acts of omission or cognitive failures
What is a reasoned violation?
Deliberate deviation from protocol based on what is thought to be in the patient’s best interests.
What is a situational violation?
Context dependent violation due to low staffing, time-pressures or lack of supervision.
What is a routine violation?
Violation hat has become normal within a setting.
What is a latent error?
Develops over time to cause an adverse event due to:
Inadequate staff training
Working environment conditions
Socio-cultural factors
How does culture lead to error?
Blame culture means that there is incentive to cover up for fear of retribution
Normalisation of deviance within a team means that staff become tolerant of malpractise
What increases the risk of adverse errors?
Unfamiliarity with the task
Inexperience
Time pressure
Poor procedures
Inadequate checking
