Ensuring patient safety Flashcards
What is patient safety
The avoidance, prevention and amelioration of adverse outcomes or injuries
Define adverse event
Any event or circumstance arising during care that could have or did lead to unintended or unexpected harm, loss or damage
Define a near miss
Any incident that could have led to harm but did not, either by chance or by timely intervention
Define a significant event
Any signifcant event, positive or negative during the care of a patient
What is an error
The failure of a planned action to achieve its intended outcome
What are mistakes a result of
Rule and knowledge based errors
What are lapses based on
skill based errors, memory failures
What are slips based on
Skill based errors- attetional failure
What are active errors
Noticed first
on frontline operator
effects felt immediately
difficult to predict
What are latent errors
Less apparent failures
result from organizational design
gernerally results from lack of standardistation of equipment and processes
What is human error attributable to
human cogntition and limitation of memory
cant remember everything
cut corners?
What human factors might contribute to the risk of error
Unfamiliarity inexperience time failure to check and confirm poor procedures to complete task poor equipment design/ease of use
What reduces attention and memory
Fatigue stress hunger illness language or cultural barries hazardous activites
What are the individual factors that predispoe to error
Distraction
attention and memory deficits
multitasking or deviation from routine
knowledge based thought from past experience
Explain the swiss cheese model
Many holes in the cheese, some are active errors, some are latent errors. Hazards can either be deflected or sometimes mutiple errors or holes lead to an adverse event- sucessive failur of mutiple defences, barriers and safeguards
What should be done if an error is made
First manage the patient
analyse the situation
accept the responsibilty
never blame, point fingers, or gossip
What are the 5R’S
Right drug route time dose patient
Which patients are at higher risk of medication error
Patients with
multiple conditions + doctors + medications
problems with communication
do not take an active role in disease management
children and babies
When should you HALT
if your hungry angry late or tired
How do you know your safe
Illness Medication Stress Alcohol Fatigue Emotion
What is the optimum goal for establishing a safety culture
acknowledgement of risks
group responsibilty
safety above financial and opperational goals
system encorages and rewards identification of issues
incidents are learning oppertunities
appropriate resources structures and accountability
What barries exist to safety
Fear Whos responsibilty is it takes too long extra admin no patient impact
What are clinical audits
quality improvement process that seeks to improve patient care adn outcomes through systematic review of care against explicit criteria
