Patient Safety Incidents Flashcards
(7 cards)
⚠️ 2. Types of Unsafe Acts
A. Human Error (Unintentional)
Three performance levels:
Skill-based: Routine actions
Slip: Wrong action (e.g., counting tablets instead of days).
Lapse: Forgetting (e.g., forgetting to switch to discharge meds).
Rule-based: Using a known rule
Mistake: Misapplying rule (e.g., choosing a contraindicated drug).
Knowledge-based: No rule exists; relies on reasoning
Mistake: Incorrect reasoning (e.g., wrong brand substitution).
Contributing factors:
Skill-based: Triggered by misleading cues (e.g., labels).
Rule-based: Misapplication of rules.
Knowledge-based: Cognitive limitations (e.g., confirmation bias).
B. Procedural Violations (Intentional, but not malicious)
Deliberate deviations from SOPs/protocols.
Four types:
Routine violations: Regular practice (e.g., using labels instead of Rx).
Optimising violations: For secondary gains (e.g., pleasing customers).
Situational violations: Context-dependent (e.g., time pressure).
Exceptional violations: Unique scenarios (e.g., giving expired meds in emergencies).
💊 What to Do if a Patient Safety Incident Occurs
Example: Wrong OTC medicine supplied to child.
• Encourage the patient to tell you what has happened
• Listen and ask further questions if necessary
• Tell them you are sorry for the distress/harm that has been caused - even if it wasn’t you who was involved
• Find the prescription and inspect the incorrect medication. If the patient is happy to let you, retain it as evidence
• Take notes
• Exchange contact details
• Tell the patient what you propose to do
• Negotiate any other next steps the patient needs/wants to happen
• If they want to take it further tell them how to do this (e.g. GPhC, NHS or your employer’s complaints procedure)
• Replace with the correct medication
Try to find out the level of harm
- Has the patient taken it?
- If so, how many and for how long?
- Any symptoms?
- Spoken to the doctor?
- What is the medical history?
• Follow your SOPs
• Contact the prescriber if medication taken
• With the prescriber, decide the next steps for the patient and relay this to the patient
• Report the incident
• Notify the pharmacist on duty if it was not you
• Inform your indemnity insurer
• Investigate and brief the team
• Follow up the patient to ensure he/she is okay
Chat:
Listen to the patient.
Acknowledge the incident and express regret.
Inspect the medication and prescription.
Keep the incorrect item (with consent).
Take notes and record details.
Inform the patient of next steps.
Offer support: Direct them to complaints procedures if needed.
Replace the medication.
Assess harm: Has the incorrect medicine been taken?
Contact prescriber if harm is possible.
Follow SOPs, notify responsible pharmacist, report the incident.
Inform indemnity insurer.
Incident Investigation: The London Protocol
Purpose:
Systematic analysis to learn from incidents and implement safety improvements.
Seven Steps:
Decide to investigate (based on seriousness or learning potential).
Form investigation team (e.g., pharmacy managers, experts).
Gather data (staff records, SOPs, interviews, etc.).
Establish chronology (timeline or time-person grid).
Identify care delivery problems (errors/violations).
Identify contributory factors (see categories below).
Make recommendations (improvements, priorities, and responsibilities).
5 Whys technique (ask “why?” repeatedly to uncover root causes)
⚠️ Caution with “5 Whys”: Can oversimplify complex systems; may miss other causal paths.
Contributory Factors in Incidents
Patient
Task & equipment
Individual staff
Team communication
Work environment
Education & training
Organisation and management
Institutional context
Making Actionable Recommendations
Identify what needs to be done.
What how when and with what
Assign priority and propose implementation methods.
How will know the actions have been implented
If external, provide general recommendations (site-specific teams implement details).
Accountability vs Systems Thinking
System-Centred View:
Focuses on how systems enable or constrain performance.
Avoids unfair blame on individuals.
When to Consider Individual Accountability:
Use NHS Improvement’s Just Culture Guide:
Were actions reasonable in the context?
Were there health issues or malicious intent?
Substitution test: Would someone else in the same situation act similarly?
👉 Depending on answers:
Retraining
Occupational health referral
Disciplinary action
No action if systems are at fault
So - instead of searching for a root cause, think about how different parts of the work system come together to create an incident
• The SEIPS model (from year 2 medication safety) might help with this
• Remember that contributory factors can interact in complex or subtle ways, as demonstrated in last semester’s systems thinking workshop
Summary Checklist for Exams
✅ Know the three types of human performance (skill, rule, knowledge) and related errors.
✅ Distinguish errors vs violations (intentionality is key).
✅ Recall the 4 violation types and examples.
✅ Describe steps to respond to a safety incident.
✅ Understand and apply the London Protocol.
✅ Be able to discuss contributory factors and analysis tools.
✅ Balance system-based thinking with professional accountability.
