Adverse events in healthcare Flashcards
What is an adverse event?
An unintended event resulting from care and causing patient harm
What is a near miss?
A situation in which events or omissions arise during clinical care, but fail to develop further
Give some examples of adverse events
- Wrong site surgery
- Medication errors
- Pressure ulcers
- Wrong diagnosis
- Failure to treat
- Patient fall
- Hospital acquired infection
- Medicine side effects
What percentage of hospital deaths are avoidable?
3.6%
How do we know if a hospital is safe?
- Hospital mortality data
- Data on other measures of safety
- reports of never events and serious incidents
- NHS safety thermometer
- patient safety dashboards - Monitoring and inspections by regulators
- CQC
- NHS improvement
What is the Swiss cheese model of accident causation? Explain it!
It is a model used in risk analysis and risk management:
- It likens human systems to multiple slices of Swiss cheese, stacked side by side, in which the threat becoming reality is mitigated by the different layers of defences which are ‘layered’ behind each other
- Therefore, in theory, lapses and weaknesses in one defence do not allow a risk to materialise, since other defences also exist, to prevent a single point of weakness
- Although many layers of defence lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the accident to occur
What is the difference between system and individual error?
System error looks for explanation of its causes in the wider system but individual error looks for explanations of its cause in people!
- System error looks at procedures, practices, technology, communication, and the working culture
- Individual error can be traced back to the fault of an individual or individuals that make a wrong decision or were not paying attention
Outline the main reasons for system and human error (active vs latent failures)
- Active failures: unsafe acts committed by people in direct contact with patients
- Knowledge based
- Rule based
- Skills-based
- Violations - Latent failures: develop over time and lay dormant until they combine with other factors or active failures to cause an adverse event
- Importance of culture: blame culture, normalisation of deviance
- Human factors: nature of human fallibility, inevitability of error, error that is not necessarily due to incompetence
Give some situations with an increased risk of error
- Unfamiliarity with the task
- Inexperience
- Shortage of time
- Inadequate checking
- Poor procedures
- Poor human equipment interface
What do you do when an adverse incident occurs?
- Report it
- Assess its seriousness
- Analyse why it occurred - root cause analysis
- Be open and honest with the affected patient and apologise - Duty of Candour
- Learn from the event and put in place actions to reduce risk of repeat
What can you do to improve patient safety and prevent adverse incidents?
- Participate actively in the improvement of systems of care and acquired skills to do so
- Speak up when things go wrong
- Involve patients as partners in their own care
- Learn from patient and clinician stories
What are the adverse events in maternity care? (system vs individual causes)
System causes:
- Communication difficulties
- Lack of team working
- Poor working relationships between different consultants and between consultants and midwives
- Poor support for staff from human resources
- Staff shortages
- Lack of policies in some units for dealing with PE, eclampsia, or haemorrhage
- Lack of effective data collection for audit
- Poor staff attendance at training sessions
Individual causes:
- Human error
- Wrong diagnosis
- Failure of junior staff to diagnose or refer a case to a more senior colleague
- Inadequate supervision by senior staff
- Inadequate foetal monitoring
- Mismanagement of forceps deliveries
