Flashcards in Risk and Errors Deck (27):
Define a medication error
Department of Health (2004)’s definition:
“A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer.”
What is the Root Cause Analysis?
1. Evidence-based & structured investigation
2. Aim to identify true cause of a problem and the actions needed to eliminate it
3. Understand what, why and how a system failed
Describe the RCA process? (7)
1. Identify incident
2. Gather information and map the incident (timeline of events)
3. Identify care & service delivery problems
4. Analyse problems (brainstorming, nominal group technique)
5.Generate solutions and recommendations
6. Implement solutions
7. Write report
When to conduct a RCA?
1. After a serious incident
2. After a series of incidents or near misses
What is the nominal group technique?
Ideas discussed and rationalised, ranked 1-5, prioritised by ranking scores
What is the 5 whys technique involve?
Asking "why is that" 5 times
1. What is happening?
then why is that ....
What is the Swiss Cheese Model?
Successive layers of defences, barriers and safeguards. There are holes in each layer representing what could have allowed something to go wrong such as latent conditions, unsafe acts, organisation issues.
Leading to failed defences
What is the Reason's Organisational Accident Model?
Based on the error theories described above Vincent and colleagues created a framework for the analysis of adverse events and critical incidents in healthcare. This framework includes active failures, error and violation producing conditions, and latent conditions.
What are the key principles for solution design? (6)
1. Simplify tasks, processes and protocol
2. Standardise processes and equipment
3. Minimise dependency on short-term memory and attention span
4. Avoid fatigue
5. Improve reliability in delivery of quality care
6. Retraining is not always the right solution
What are some of the limitations to a RCA? (5)
1. Time consuming
2. Difficult to achieve involvement
3. Difficult to be blame free
4. Bias – cognitive,hindsight, outcome
5. Memory degradation
Explain what cognitive, hindsight and outcome bias is?
1. A cognitive bias is a mistake in reasoning, evaluating, remembering, or other cognitive process, often occurring as a result of holding onto one's preferences and beliefs regardless of contrary information.
2. Hindsight bias, also known as the knew-it-all-along effect or creeping determinism, is the inclination, after an event has occurred, to see the event as having been predictable, despite there having been little or no objective basis for predicting it.
3. The outcome bias is an error made in evaluating the quality of a decision when the outcome of that decision is already known.
Describe what human factors encompass
All those factors that can influence people and their behaviour.
In a work context, human factors are the environmental, organisational and job factors, and individual characteristics which influence behaviour at work
How do you use human factors to reduce errors
Have to accept that a vast majority of people come to work to do a good job
Mistakes are usually caused by ineffective systems not bad people
Systems should be designed to do the right thing
Create a culture where human error is seen as a source of important learning
Taking responsibility for safety whoever we are, where ever we are
Describe what is safety I
Definition- As few things as possible go wrong
Safety management principle- Reactive
Explanation of accidents- caused by failures and malfunctions, purpose of investigation identify causes and contributory factors
Attitude to the human factor- humans as a liability or hazard
Role of performance variability- harmful- should be prevented as far as possible
What is the root cause analysis process and describe it
Gather information and map incident
- Investigate interviews, those involved, witnesses
- Site visit/reconstruction/ Sketch site of incident with photos
- Documentation review- gather documents and written accounts
- Equipment quarantine where appropriate
- Organise all information into chronological timeline and resolve gaps or inconsistencies with timeline
Identify care and service delivery problems
- swiss cheese model- holes due to active failures
Analyse problems and identify CFs and root causes
- Brainstorming or brain writing
- 5 way's keep asking why did this happen?
- Fishbone- patient factors, individual, task factors, communication factors, team factors, education or training factors, equipment + resources, working condition factors, organisational and strategic factors = problem or issue
Generate solutions and recommendations
- Stronger actions- change cultural approach
- Moderately strong actions- effective use of skill mix
- Weaker actions- double checks, warning labels
Effectiveness is higher from weaker actions
- Simplify tasks, processes and protocols, standardise processes and equipment, avoid fatigue,
- Respond to incidents
- Increase confidence or create fear?
- Identify weakness
Write the report
What important questions must be asked in the prospective methods of risk assessment
What can go wrong
Is there a need for action
Why do risk assessment? (6)
1. Help improve work and care delivered
2. Balance risk reduction with supporting innovation
3. Support better decision making
4. Helps plan for uncertainty
5. Increase patient and public confidence
6. Highlights weaknesses in procedures, practices and policy changes
What factors depend on when you do root cause analysis?
Degree of harm or damage caused at the time
Realistic future potential for harm if it occurred again
Better to do fewer RCAs well than consider it as an ending in its own right
How is risk assessment associated with purchasing for safety?
Risk assessment of products as part of healthcare contracting and purchasing
Safety before price, purchase products with following:
- Clear labelling and packaging
- Well differentiated similar products to prevent misidentification
- Appropriate secondary and warning labels
- Bar codes
- Ready to administer/use or simple preparation and administration
- Adequate information for practitioners, patients and carers
What is the failure modes and effects analysis (FMEA)?
Systematic proactive method for evaluating a process
Identify where and how it might fail
Assess relative impact of different failures
Identify parts of the process that are most in need of change
What does FMEA do, when do you use it and what does it identify?
What does it do
- Identify potential points of failure and effect on individuals and organisations
When to use it
- Useful for new process and process change
What does it identify
- Failure mode- what could go wrong
- Failure cause- why it could go wrong
- Failure effect- consequences of failure
What is the risk matrix?
When all actions should be directed towards achieving optimal reduction in severity and/or likelihood
Result = a collective perception of risk rather than a precise, objective measure of risk, but as such still VERY valuable.
Objectivity and precise science may be difficult in many areas and this provides a valuable and valid means of working with and communicating about risk in that arena.
What are the benefits (5) and constraints (2) of FMEA?
Systematic, thorough, consistent
Ensure care is fit for purpose
What interventions can you have for prescribing
Electronic prescribing and computerised decision support
Audit, reporting systems
What is safety II
Definition: As many things as possible go right
Safety management principle: proactive
Explanation of accidents: Activities happen in the same way, regardless of outcome
How things go right to explain how things go wrong
Attitude to the human factor: humans as a resource, flexibility and resilience
Role of performance variability- inevitable but also useful, monitored
Why and how things go right
Safety as an emergent property of a resilient healthcare organisation
Describe what is organisation resilience
Property of working environment
Ability to cope and respond to demands effectively
Creating environments so patient care can take place safely
4 key capacities: RLMA
- Respond: how and when- resources
- Learn- past experiences and share that knowledge
- Monitor- what, reliability and continuous
- Anticipate- uncertainties