Clinical Errors

Question 1

Clinical Reasoning Errors (define)

Answer 1

Errors of reasoning or decision-making caused by ‘cognitive distortions’ or ‘unhelpful thinking styles’ based on inaccurate beliefs and biases. Incl. failures to elicit, synthesise, decide or act on clinical information.

Question 2

8 CREs

Answer 2

1. Anchoring
2. Attribution bias
3. Ascertainment bias
4. Availability bias
5. Confirmation bias
6. Over-confidence
7. Pre-mature closure
8. Diagnostic momentum

Question 3

Anchoring (define)

Answer 3

(Sticking with an initial diagnosis)
Prematurely settling on a single diagnosis based on a few salient features of initial presentation and failing to adjust to (or disregarding) new information (compounded by confirmation bias).

Question 4

Confirmation bias (define)

Answer 4

(Looking for what you want to see)
Tendency to seek confirming evidence to support a nursing diagnosis and overlook or discount disconfirming evidence even where the latter is more persuasive/definitive.

Question 5

Ascertainment bias (define)

Answer 5

(Seeing what you expect to see)
Stereotyping patients and allowing thinking to be shaped by prior expectations – e.g. gender bias, ageism, racism.

Question 6

Availability bias

Answer 6

(Picking the easiest answer)
Judging the likelihood of disease by the ease with which relevant examples come to mind such that recent experiences influence the likelihood of certain diagnoses being made. Includes recent/significant case bias – a rare diagnosis that was seen recently or had a significant impact on the clinician dominates the differential.

Question 7

Diagnostic momentum

Answer 7

(Labelling a patient)
Once a potential diagnostic label is attached to a patient it gathers increasing momentum until it is considered definite and other possibilities are excluded

Question 8

Attribution bias

Answer 8

(Blaming the patient)
Tendency to be judgemental and overly attribute a patient’s problems to their disposition, instead of considering external/situational factors. Includes psych-out error - overlooking or minimising co-morbid conditions or overweighting the individual’s personality in the diagnosis of psychiatric conditions.

Question 9

Overconfidence bias

Answer 9

(Too much self-belief)
Tendency to place too much faith in one’s opinion and acting on incomplete information, intuition or hunches instead of evidence.

Question 10

Premature Closure

Answer 10

(Cutting the process short)
Accepting a diagnosis too early in the diagnostic process before all necessary information has been gathered and alternatives explored. Compounded by unpacking principle – failure to elicit all relevant information in establishing a differential diagnosis.

Question 11

Consequences of CREs

Answer 11

Inaccurate or incomplete reasoning process –> diagnostic errors (missed, incorrect or delayed diagnoses) –> treatment errors (unnecessary, adverse, delayed or overlooked treatment options) –> poor patient outcomes (complications/disabilities, deterioration/mortality, costs).

Question 12

Preventing CREs (Individual Measures)

Answer 12

1. Meta-cognition - analysing and critiquing thinking and reflecting on past experiences to identify biases.
2. Situational awareness - recognising circumstances where error is more likely to occur – e.g. heavy caseloads, critical/complex patients, rushed handovers.
3. De-biasing strategies - thought processes that make decisions less susceptible to bias and error (e.g. cognitive forcing, analytical reasoning, ‘thinking aloud’)
4. Decision-support resources - second opinions, feedback, CPGs/policies, closed loop communication.
5. IMSAFE checklist

Question 13

Preventing CREs (Organisational Measures)

Answer 13

1. Protocols for identifying errors - e.g. trigger tools for unplanned readmissions.
2. Ongoing professional development programmes - e.g. crisis resource management training.
3. Promoting evidence-based practice and culture of open disclosure
4. Clinical decision support systems
5. Integrated handover/information systems
6. Feedback via clinical audits, cognitive autopsies, MMRs, SEAs.

Question 14

Causes of CREs

Answer 14

1. Internal cognitive biases - clinician’s beliefs, values, emotions, personality, expectations and personal interests - e.g. ethnocentrism.
2. External cognitive biases - professional socialisation, peer opinion, organisational culture - e.g. Western biomedical model.
3. Lack of expertise - knowledge, experience or skill-proficiency.
4. Internal situational factors - stress/fatigue, ill-health, interpersonal relationships.
5. External situational factors - noise/interruptions, workload/multi-tasking, time pressure, resource limitations, staffing.

Question 15

Principles of open disclosure

Answer 15

1. Open and timely communication
2. Acknowledgement
3. Apology or expression of regret for any harm - incl. ‘I am sorry’ NOT liability, blame or speculation.
4. Supporting and meeting needs of patients, families and carers.
5. Supporting and meeting needs of healthcare workers.
6. Integrated clinical risk management and systems improvement
7. Good governance
8. Confidentiality

Question 16

Sentinel Event (define)

Answer 16

Serious clinical incidents that have (or could have) caused serious harm (physical or psychological injury) or death of patient, that is attributable to the provision (or lack thereof) of healthcare rather than the patient’s underlying condition, that could have been prevented.

Question 17

Clinical risk (define)

Question 18

Types of clinical errors

Answer 18

1. Commission - committing the wrong action - i.e. performing the wrong intervention or performing the right intervention incorrectly.
2. Omission - failure to take correct course of action - i.e. failure to detect a condition or provide an intervention.

Question 19

Causes of clinical errors

Answer 19

1. Execution errors - right intention but not performing an action correctly.
2. Rule violation - breaching rule or policy.
3. Wrong plan - wrong intention at outset, resulting in failure to achieve outcome.

Question 20

Hazardous condition (define)

Answer 20

Any set of circumstances that increase the likelihood of serious adverse outcome - e.g. inadequate nurse-patient ratios.

Question 21

10 Sentinel events

Answer 21

Patient suffers serious harm or death as a result of:
1. Surgery/invasive procedure on wrong site
2. Surgery/invasive procedure on wrong patient
3. Wrong surgical/invasive procedure
4. Unintended retention of foreign object
5. Haemolytic blood transfusion reaction due to ABO incompatibility
6. Suspected suicide of patient in acute psychiatric ward.
7. Medication error
8. Use of physical/mechanical restraint
9. Discharge of infant/child to unauthorised person
10. Incorrectly positioned oro/naso-gastric tube

Question 22

SAC1 Reporting

Answer 22

Mandatory reporting for public hospitals, private licensed health care facilities
and NGOs.
- submit investigation report within 28 days of notifying PSSU
- implement and evaluate recommendations within 6months (and refer report to PSSU)

Question 23

Clinical Risk Management (explain)

Answer 23

System and processes that aim to minimise risks and harm to patients by:
- Establish the context
- Risk analysis - identify, analyse and evaluate risks.
- Learning lessons from AEs
- Implementing prevention strategies

Question 24

Root Cause Analysis

Answer 24

The process used to analyse an adverse event/near miss to identify the root causes.
1. What happened? - gather information, construct a timeline.
2. Why did it happen? - identify factors that contributed/caused incident, link factors to the outcome.
3. What can be done to prevent it happening again? - make and prioritise recommendations.

Does NOT include - criminal acts (suspected patient abuse), intentional unsafe acts, acts related to substance use.

Question 25

7 Steps to incident management

Answer 25

1. Identification
2. Notification - i.e. CIMs
3. Prioritisation
4. Investigation
5. Analysis and action
6. Classification
7. Feedback

Question 26

Clinical incident/Adverse Event (define)

Answer 26

An event or circumstance resulting from healthcare which could have (near miss) or did lead to unintended and/or unnecessary harm to a patient/consumer.

Question 26

CIMs

Answer 26

Clinical incident management system - a reporting system developed to ensure the appropriate management of clinical incidents to prevent/reduce future harm in public hospitals/health services.
1. Responses - identify when patients are harmed and implement minimisation strategies.
2. Education -ensure lessons are learned, provide opportunities to share lessons.
3. Prevention - identify hazards before they cause harm, treat the hazard and review clinical risks.

Question 27

5 Step approach to mistakes

Answer 27

1. Identify and reduce - determine seriousness, immediate management.
2. Policy and procedures - e.g. needle-stick injuries.
3. Document
4. Reflect on lessons learned
5. Analyse specifics of mistake

Question 28

Tips for prevention

Answer 28

• Develop situational awareness - types, causes and management of errors.
• Follow policy and procedures
• Used systematic approach - ADPIE, DRSABC, checklists, plans.
• Understand rationale for interventions & medications