BHP II Flashcards
simple definition of error?
dong the wrong thing when meaning to do the right thing - Runciman
Adverse Event ?
An injury caused by medical management rather than underlying condition of the patient
Violation?
A deliberate deviation from an accepted protocol or standard of care
Errors terbagi 2 yaitu
Skill-based slips and lapses
Mistakes
Skill-based and lapses error terbagi 2
- Attentional slips of action
- Lapses of memory
Mistakes terbagi 2
- Rule based mistakes
- Knowledge based mistakes
Situations associated with an increased risk of error
CUTI PH
- inadequate checking
- unfamiliarity with the task
- Shortage of time
- Inexperience
- Poor procedure
- poor human equipment
Individual factors that presdispose to error
- Limited memory capacity
- Further reduced by: fatugue, stress, hunger, illness, language/cultrual factors, hazardous attitudes
- HALT (hungry, Angry, Late, Tired)
A performance-shaping factors
IM SAFE Illness Medication Stress Alcohol Fatigue Emotion
Incident monitoring is..
-involves collecting and analysing information about any events that could have harmed or did harm anyone in the organization (KUMPULKAN INFORMASI YG DPT MEMBAHAYAKAN)
Culture: a workable definition
Shared values (what is important) and beliefs (how things work) that interact with an organization’s structure and control system to produce behavioural norms (the way we do things around here)
Incident reporting and monitoring strategies
others include
-anonymous reporting
- timely feedback
- open acknowledgement of successes resulting from incident reporting
-reporting of near misses
. “free lessons” can be learned
. system improvements can be instituted as a result of the investigation but at no “cost” to a patient
RCA model, a Rigorous, Confidential Approach to answering…
- What happened?
- Why did it happen
- What are we going to do to prevent it from happening again
- How will we know that our actions improved patient safety?
RCA model focus on..
- prevention, not blame or punishment
- system level vulnerabilities other than individual performances
Personal error reduction strategies
- know yourself
- know your environment
- know your task
- preparation and planning
- build “checks” into your routine
- Ask if you don’t know
Mental preparedness
- assume that errors can and will occur
- identify those circumstances most likely to breed error
- have contingencies in place to cope with problems, interruptions and distructions
- mentally rehearse complex procedures
Why is medicine so suspectible?
• Lack of awareness to the problem
- “Culture of Silence”
Blame and shame mentality •
- System constrain – – – –
Staffing problems
Fatigue
Knowledge requirements Communication and continuity of care
Medical negligence is.
Failure to meet the standard of practice of an average qualified physician practicing in the specialty in question
occurs merely when there is an error but when the degree of error exceeds the accepted norm
Reasons why people sue their doctors
Advised to sue by influential other Needed money Believed there was a cover Child would have no future Needed information Wanted revenge, license
