Block 11 - part 1 Flashcards
Patient safety
Coordinated efforts to prevent harm to patients caused by the process of health care itself
Adverse event
unintended event resulting from clinical care and causing patient harm
near miss
situation in which events arise during clinical care but fail to develop further
Swiss cheese model of accident causation
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
individual error
errors of individuals, blames individual for forgetfulness, inattention or moral weakness
system error
conditions under which an individual works, tries to build defences to eliminate errors or mitigate their effect
active failures
unsafe acts committed by people in direct contact with the patient, usually short lived, often unpredictable
latent error
development over time until they combine with other factors or active failures to cause an adverse event, long lived and often can be identified and removed before they cause an adverse event
knowledge based error
forming wrong intentions or plans as a result of inadequate knowledge or experience
rule based error
encounter relatively familiar problem but apply wrong rul, either misapplication of a good rule or application of a bad rule
skills based error
attention slips and memory lapses, involve the unintended deviation of actions from what may have been a good plan.
main reason we are prone to skills based errors
interruption and distractions
violations
deliberate deviation from some regulated code of practice or procedure
why do violations occur
people intentionally break the rules
4 types of violations
routine
reasoned
reckless
malicious
routine violation
regularly performed shortcuts due to system, process or tast being poorly designed or actions. May become tactically accepted practise over time
reasoned violation
occasional reasoned deviation from a protocol or procedure which we believe we have good reason for making (e.g. time constraints), may be in pts best interests
reckless violation
deliberate deviations from a protocol/code of conduct and include acts where opportunity for harm is foreseeable and ignored, although harm may never be intended
malicious violation
deliberate deviations from a protocol/code of conduct, where the intention is to cause harm
systems in place in NHS to prevent errors occuring
National patient safety agency (NPSA) 2001,
National reporting and learning system (NRLS) 2004,
Medicines and healthcare - products regulatory agency (MHRA)
How do we know 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 (care quality commision (CQC), NHS improvement)
Situtions associated with increased risk of error (6)
Unfamiliarity with task, inexperience, shortage of time, inadequate checking, poor procedures, poor human equiptment interface
what should we do when adverse incidents occur
report it,
assess seriousness,
analyse why it occured,
be open and honest with affected patient and apologise,
learn from event and put in place actions to reduce risk of repeat
common causes of death and contact with hospital in children in developing countries
Infection, diarrhoea, malaria, HIV, malnutrition, kwashiorkor, sanitation, water supply, food hygeine
