Patient Safety Flashcards
(27 cards)
Stages of 2nd Victim Syndrome
- Chaos and accident response
- Intrusive reflections
- Restoring personal integrity
- Enduring inquisition
- Obtaining emotional 1st aid
- Moving on
Harm
A -ve effect, whether or not it is evident to patient
Unavoidable harm
-ve effect that can’t be prevented
not caused by error
Hazard
Potential source of harm
Error
Unintended act (omission/ commission) or one that doesn’t achieve its intended outcome
Action error - failure of planned action to be completed as intended
Thinking error - wrong plan to achieve aim
Adverse Event
Undesirable experience associated with the use of product or procedure
Near Miss
Errors that occur in process of providing medical care that are detected and corrected before a patient is harmed
Sentinel Event
Patient safety event that results in death, permanent harm, severe temporary harm
Human Error
Thinking Error
- Decision making error
- Error judgement
- Wrong plan used to achieve aim
Action Error:
- Slips and lapses
- Error in execution of correctly planned action
Thinking Error
- Decision making error
- Error judgement
- Wrong plan used to achieve aim
- Action carried out as planned
- Conscious thought process
- Wrong course of action taken
- Lack experience
- Insufficient or incorrect information
Rule Based Errors:
- Good rules not applied/ misapplied
- Apply bad rule
Reducing Thinking Errors:
- Support from experienced colleagues
- Challenge info received
- Self reflection
- Awareness of confirmation bias
Standard operating procedures
Effective patient handover
Mentoring and debriefs
Emergency protocols
Action Errors:
Slips
- Attention based error
- Dispense the wrong meds
- Miscalculating fluid rate
- Writing clinical record under wrong animal
- Xray wrong leg as didnt read notes
properly
- Recognition and selection errors
Lapses
- Memory based error
- Attentional Failure
Error in execution of correctly planned action
HALT & PPP
Hungry +/- thirsty
Anxious +/- Angry
Late +/- lonely
Tired
Plan
Prioritise
Pause
How to Reduce Action Errors:
Checklists
Reminders and alarm warning systems
Cross checking vital tasks
Reduce/ remove distractions
Sufficient time
Reason’s Swiss Cheese Model of Accident Causation
Successive layers of defence, barriers and safeguards with some holes due to active failures - other holes due to latent conditions
Near miss:
- error doesnt reach patient
Errors in Accident Causation:
Active errors
- Known flaw/ hazard
- Unsafe act committed within system/by patient
- HARM
Latent Errors:
- Unknown flaw/ hazard
- Dormant in system
- Not yet contributed to error
- Hasn’t caused harm yet
Blame Culture
People/ teams are blamed for mistakes and errors
Leads to reluctance to accept responsibility
Causes:
- Minimal emotional support
- Poor emotional intelligence
- Lack compassion
Blame Culture Consequence
Higher levels of staff turnover
Reduced levels of job satisfaction
Decision escalation, continually referring to managers for decisions
Reduced responsibility taking
Lower levels of innovation and organisational
Reduced work engagement and productivity
Just Culture
Systems of Shared Accountability
- Organisation, employee
Employee Duties:
- Produce and deliver results
- Follow procedure
- Avoid causing unjustifiable risk/ harm
Routine Non-Compliance Violation
Deliberate deviation from rules
Rules no longer apply
Lack enforcement
Situational Non-Compliance
Knowingly take short cuts/ fail to follow procedures
Situation specific pressures - time, workload, equipment
Exceptional Non-Compliance
Well meaning but misguided
Something has gone wrong -> taking risk by breaking rules to solve
Exacerbated by management - get the job done
Reckless Behaviour in a Just Culture
Deliberate and conscious disregard with knowledge of risk involved
Repeated non-compliant behaviours
Disciplinary actions
Consequences for behaviour
High Reliability Organisations
Potential for large scale risk and harm
Balance
- Effectiveness
- Efficiency
- Safety
