Advanced Concepts in Medication Safety Flashcards
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
Describe what is root cause analysis
An evidence based structured investigation that usually occurs after a serious incident or near miss
Identify the true causes of a problem or incident, and the actions necessary to eliminate it
Understand what, why and how a system failed
Symptoms of the problem- the weed
Underlying causes- the root
What is the root cause analysis process and describe it
Identify incident
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,
Implement solutions
- Respond to incidents
- Increase confidence or create fear?
- Identify weakness
Write the report
What are the limitations behind root cause analysis
time consuming
Difficult to achieve involvement
Difficult to be blame free
Bias- cognitive, hindsight, outcome
Memory degradation
What important questions must be asked in the prospective methods of risk assessment
What can go wrong
How bad
How often
Is there a need for action
Why do risk assessment
Help improve work and care delivered
Balance risk reduction with supporting innovation
Support better decision making
Helps plan for uncertainty
Increase patient and public confidence
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
- Process
- 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
What are the benefits and constraints of FMEA
Benefits:
Improved design
Multidisciplinary
Systems based
Systematic, thorough, consistent
Ensure care is fit for purpose
Constraints:
Time consuming
Frustrating
What interventions can you have for prescribing
Tools:
Electronic prescribing and computerised decision support
Education:
Training
Audit, reporting systems
Improvement projects
Professional roles:
Pharmacists
