Patient Safety Flashcards
What are latent conditions that pose a risk to patient safety?
Latent Conditions are found in the design of a system
* e.g. poor training, inadequate supervision, ineffective
communications, inadequate staffing, equipment problems,
machinery design
What are active failures that pose a risk to patient safety?
Active Failures are incorrect actions by humans
* slips, lapses, mistakes and violations
Define complexity
Give an example of complexity in the NHS
“the interrelatedness of components of a system”
The more people our patients see the more complex the issues become
Examples of systems in the NHS: Electronic records are shared with other practitioners and record systems interact with hospital and primary care record systems. They can therefore be accessed by a myriad of different
people along a patient care pathway.
How does WHO define patient safety?
‘The prevention of errors and
harm to patients’
Describe Safety 1
- how does it define safety?
- what determines the outcome?
- what role do humans play in safety management?
Less realistic model- expecting very few things to go wrong and then reacting to them if they do
Safety is defined as as few things going wrong as
possible- more negative
The outcome is determined by ‘work-as-imagined’
Humans are a liability or
hazard.
Describe Safety 2
- how does it define safety?
- what determines the outcome?
- what role do humans play in safety management?
More realistic model- aiming to get as much right as possible but expecting problems and anticipating them by forward-planning
Safety is defined as as many things going right as possible- more positive
The outcome is determined by ‘work as done’
Humans are a resource necessary for
flexibility and resilience
What is the difference between work as imagined and work as done?
Work-As-Imagined describes what should happen under normal working conditions. Work- As-Done, on the other hand, describes what actually happens, how work unfolds over time in complex contexts.
What are the limitations of Safety 1 as a model?
Safety I is based on assumptions that:
- Work-As-Imagined is same as Work-As-Done
- Work can be completely analysed and prescribed
- People behave as they are expected & trained to
- Training, policies and procedures cover every contingency
- Systems and processes are well-designed and correctly maintained
- Systems are equipped with appropriate response capabilities
- Should things go completely wrong, linear investigations or RCA can get to the bottom of it all in every case
