ASBHDS III - Session 4 - Lecture 1 - Systems Thinking Flashcards
1 - Title
Quality and Safety in Healthcare:
Systems Thinking
“Systems thinking is separate from systems: ST is how you approach it.”
2 - GMC
Professionalism: General Medical Council
3 - GMC
Medical students: professionalism and fitness to practise
4 - Achieving good medical practice: guidance for medical students GMC
Achieving good medical practice: guidance for medical students
Medical Schools Council
General Medical Council
“Telling people when things go wrong is actually one of the requirements, especially if you are present in the scenario.”
5 - Professionalism: Patient Safety
imagination at work
Professionalism: Patient Safety
Patient Safety Culture vs. Fear of Reporting.
While global efforts aim to create a culture of safety in today’s hospital, even in environments with an established patient safety culture, nurses fear punishment for reporting.
85% of nurses agree that their hospital has a patient safety culture
91% UK
85% US
80% China
However, that does not always translate into practice
60% of nurses who agree that their hospital has a patient safety culture also agree that nurses often hold back on reporting near-misses in fear of punishment
66% US
64% UK (hold back)
50% China
http://newsroom.gehealthcare.com/patient-safety-challenges-in-nursing-identified-in-global-survey/
“So of those who said they had a culture of safety – how many held back due to a fear of punishment/retribution … and then even filling in that survey people will be wary of, so these statistics may be underestimated.”
6 - Radio 1
BBC Radio Leicester: 31 July 2014 at 8.07 a.m.
https://www.bbc.co.uk/programmes/p0232b89
7 - Why does healthcare not learn from failures? - Paper
Why does healthcare not learn from failures?
https://www.hbs.edu/faculty/Pages/item.aspx?num=14310
Ref.: Tucker A, Edmondson A. Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change. California Management Review 2003 Jan; 45(2): 55-72
https://journals-sagepub-com.ezproxy3.lib.le.ac.uk/doi/pdf/10.2307/41166165
“Remember that the people who submitted to the survey were the ones who thought they had nothing to hide – the hospitals who thought they had shortcomings did not respond.”
8 - First Order Problem Solving
First Order Problem Solving
Two implicit strategies when you encounter a problem:
• do what it takes to continue patient care task, no more no less:
> meets immediate needs
> minimises time away from patient care
• ask for help from people who are socially close rather than those who are best equipped to correct the problem:
> preserves reputation
> minimises difficult encounters
Ref.: Tucker A, Edmondson A. Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change. California Management Review 2003 Jan; 45(2): 55-72
9 - Reasons for Not Learning from Failures
Reasons for Not Learning from Failures
Organisations emphasise:
• individual vigilance – i.e. personal responsibility to resolve problems to immediate tasks
• unit efficiency – i.e. unit’s throughput efficiency
• worker empowerment – i.e. delegation to workers who have little influence on external factors
Ref.: Tucker A, Edmondson A. Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics That Inhibit System Change. California Management Review 2003 Jan; 45(2): 55-72
10 - The Case of Jack Adcock: Individual Vigilance
The Case of Jack Adcock: Individual Vigilance
Dr Hadiza Bawa-Garba (left) and agency nurse Isabel Amaro (right) were both found guilty of manslaughter by negligence and have been struck off their respective professional registers.
11 - Tort Law
Tort Law: Four Elements of Civil Negligence
- The defendant owed a duty of care
- The defendant was in breach of that duty
- The breach of duty caused damage
- The damage was foreseeable
So, it is possible to be in breach of the duty of care [aka ‘error’] and not be negligent if the breach did not cause damage [i.e. ‘unharmed’] or if the damage was not foreseeable [e.g. ‘unlucky’].
Ref.: Donoghue v Stevenson [1932] UKHL 100
http: //e-lawresources.co.uk/negligence.php
http: //www.e-lawresources.co.uk/Negligence.php
“1. You cannot deny you have a duty of care if you are a doctor, When you are a civilian, or even a medical student, you can say it’s not your problem - you don’t have duty of care to the pt. But once you’re a doctor, more difficult. Default stance - if you’re a doctor, you have a duty of care,
- Quite often if you have a duty of care, if you can demonstrate that breach,
- that breach had to cause damage. You can make mistakes till the cows come home, as long as no damage arises. Make sure you cover the stuff that’s dangerous - but if there’s no damage, then there’s no negligence.
- The last bit was what they called proximity in legal terms, they mean that damage was foreseeable: it wasn’t just bad luck, if it was just bad luck, and it was shown that it was just bad luck, then you haven’t caused negligence.”
https: //injury.findlaw.com/accident-injury-law/proving-fault-what-is-negligence.html
http: //www.e-lawresources.co.uk/Donoghue-v-Stevenson.php
http: //www.bailii.org/uk/cases/UKHL/1932/100.html
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