Patient Safety

Question 1

what is the Chatham House Rule

Answer 1

requires identifiable information (e.g. person/organisation name) to be anonymised when useful information is being shared outside of the defined setting.

Question 2

what is the swiss cheese model

Answer 2

hazard reaching the patient and causing error/harm to the patient likely due to
1) latent failures in initial stages
2) active failures in later stages

Question 3

what is the HFACS framework

Answer 3

identify latent and active failures that led to an adverse event

Question 4

organisation influences in HFACS framework?

Answer 4

organisation culture
operational process
resource management

Question 5

supervisory factors in in HFACS framework?

Answer 5

inadq supervision
planned inappropriate operations: operations acceptable and different during emergencies but unacceptable during normal operation.
failure to correct known problem
supervisory violation: existing rules and regulations disregarded by the supervisor

Question 6

preconditions to unsafe acts in HFACS framework?

Answer 6

1) environmental factors
- phy env
- tools/tech

2) condition of operators
- mental states
- physiological states
- physical/mental limitations

3) personnel factors
- comm, coord, planning(teamwork)
- readiness (Refers to off-duty activities for optimal performance eg adhering to crew rest requirements, alcohol restrictions, and other off-duty mandates.)

Question 7

unsafe acts in HFACS framework?

Answer 7

errors: decision errors, skill based, perceptual (sensory input degraded)

violations: routine or exceptional (isolated)

Question 8

approaches for error reduction

Answer 8

eliminate > facilitate > mitigate

eliminate opportunity for error
facilitate error spotting/chances of error
mitigate through training, policy, etc

(IN DECREASING EFFECTIVENESS)

Question 9

what is the hierarchy of actions?

Answer 9

weaker actions
- training? warnings? new procedure?

intermediate actions

stronger actions
- more permanent? involving leadership? technology?

Question 10

what is cost benefit analysis in minimising harm

Answer 10

high cost, high benefit = investment?

high cost, low benefit = don’t bother

low cost, high benefit = do first

low cost, low benefit = consider as an interim measure

Question 11

what is PDSA framework?

Answer 11

plan do study act
(cycle)

plan: basic details 5w1h, data collection methods, predict results

do: small scale first and data collection

study: study data and whether they have been satisfactory = reflect on data

act: adopt on larger scale, modify, OR monitor

Question 12

explain just culture vs no blame culture

Answer 12

just culture: only blame if justified

no blame culture: don’t blame anyone

issue: after an incident occurs, there may be pressure to take action before initiation of investigation = blame and punishment lies on the one who carried the act.

Question 13

what are considerations in incident management

Answer 13

no knee jerk blame
open minded
clarify doubts assumptions
respectful tone
confidentiality
psychosocial support

Question 14

what is the culpability decision tree?

Answer 14

systematic approach to determining extent of accountability that each individual bears for the incident
= promotes just culture

• does not eliminate human bias during investigation

were actions as intended > unauthorised substance > knowingly violate SOP > pass substitution test > history of unsafe acts?

Question 15

buidling reliability into healthcare

Answer 15

reliable = consistent high quality + exceptional safety

• occurs by design
• actions/systems in place to reduce harm/errors.

Question 16

what is the importance of open communication/disclosure?

Answer 16

medical ethics: patients’ rights to know

patients/families expect honesty, transparency, on going communication = build trust and assurance

patients/families want to know how we prevent similar error from occurring

DOES not need to be performed by healthcare professional. institution can designate a suitably trained person.