17 - Patient Safety 1 Flashcards
What is psychological identity?
- A person’s self image or mental model of themselves
What is Erikson’s theory of psychosocial development?
- Personal identity starts forming in adolescence 14-24 years
- Identity v Role Confusion
- Failure to form an identity inhibits us forming social relationships with others
What would philosphers say the factors are that make up “self”?
What is the Myers Briggs Type Indicator?
Everyone has 4 traits to their personality
- E/I: where we direct our energy
- S/I: how we deal with information
T/F: decision making
J/P: how we interact with the outer world
What are different descriptive words we can use to describe a person’s actions in conflict resolution in the workplace?
Need to know your own conflict style to be able to resolve it
What is the three bucket model and how can we apply it to patient safety?
- Model helps healthcare professionals assess their own error risk
- Only an estimation of the probability that there will be an error
- Full combined buckets means increased risk so need to be more vigilant and consider additional defences
What are some of the main factors involved in good quality patient safety and care?
What is the Swiss Cheese Model?
- Holes due to active failures or latent conditions
- Holes are failures in the barriers to errors
What is the difference between a never event and a patient safety incidenty?
What are some examples of never events?
A never event is a serious, largely preventable patient safety incident that should not occur if the available preventable measures have been implemented
How do we define good quality healthcare and how do we check that this is occuring?
- Audits
- Protocols
- Checklists
- Effective communication
- Interprofessional team working e.g MDTs
What are some human factors that can compromise patient safety?
What is situational awareness and some red flags of poor situational awareness?
- We may miss things and may make assumptions
What is NatSSIPS?
Any invasive procedure beyond cannulation that could lead to a never event. Certain steps have to be followed, e.g black arrow on leg
What is the Sharp and Blunt end theory?
At sharp end, active failures or unsafe acts (e.g. slips, lapses, mistakes and violations) can occur on the part of frontline workers.
‘mistakes’ and ‘violations’ can occur when an incorrect plan is formulated and then followed.
Active failures do not occur in isolation, but result from ‘error-producing conditions’ that arise at different levels within the system
What is a good safety culture?
- Collection of the beliefs, perceptions and values that employees share in relation to risks within an organisation
- Good safety culture means good safety performance
What is transactional analysis?
- Theory that explains why we think, act and feel the way we do
- We have three ego states that we activate in our transactions e.g if we had conflict with colleague we would activate adult mode as based on what is happening here and now
What is the civility saves lives program?
A way to improve patient safety by stopping senior doctors belittling their juniors (google)
What are the three levels of situational awareness?
Perception: noticing cues e.g patient’s vital signs
Comprehension: what do cues mean in relation to the patient
Projection or Anticipation: prediction of what will happen in the near future, e.g doctor recognises warning signs and realises patient will detiorate in a few minutes so takes actions to prevent this
What is the duty of candour?
- Provide the patient and other other relevant person all necessary support and relevant information in the event of a notificable patient safety incident
- Incident is notificable when any unintended or unexpected event occurs that causes moderate or sever harm, moderate increase in treatment, prolong psychological harm, or death
How do you complete the duty of candour?
- Be open and honest with the organisation as well as the patient. Tell organisations about near misses also
What is the freedom to speak up campaign?
We need to develop a culture where staff are positively encouraged to raise issues about safety, quality and effectiveness of the service and be supported when they do so
