ethics Flashcards
drug related problems
IASE: indication, adherence, safety, efficacy
NCCMERP medication error catergories
A) circumstances/events that have the capacity to cause error
B) error occurred but did not reach pt
C) error occurred and reached pt but no harm
D) error occurred, reached pt and require monitoring +/- intervention to ensure no harm
E) error that contributed or resulted in temporary harm or intervention
F) error occurred that may have contributed harm and required initial/prolonged hospitalisation
G) error occurred and resulted in permanent harm to pt
H) error that occurred and required intervention to sustain life
I) error occurred that may have contributed/resulted in death
paradigm shift in practice of care
- medication safety: basic standard of care
- value-based care: person centred
NHG integrated quality and safety plan
- service culture
- healing environment
- operational excellence
- safety culture
- improvement culture
- clinical excellence
HFACS framework components
- goal: not to attribute blame but to understand how error came about
1) organisational influences
2) supervisory factors
3) preconditions for unsafe act
4) unsafe acts
HFACS framework - organisational factors
- organisational culture
- operational process
- resource management
HFACS framework - supervisory factors
- inadequate supervision
- operational process
- resource management
HFACS framework - preconditions for unsafe act
1) situational factors
- physical environment
- tools or technology
2) personnel factors
- communication, coordination, planning
- fitness for duty
3) conditions of operators
- mental state
- physiological state
- physical/mental limitations
HFACS framework - unsafe act
1) errors
- decision based
- skill based
- perceptual error
2) violations
- routine violation
- exceptional violations
stages in implementing new strategy
1) proactive: take preventive actions in advance
- enterprise risk management (ERM): organisational/macro approach
- clinical risk management: specific to pt care and clinical practice
- failure modes and effective analysis (FMEA)
2) reactive: actions in response to what has happened
- incident management
- root cause analysis (RCA)L manage serious clinical incident, errors w minor adverse outcomes, errors/near misses
- problem solving
- quality improvement (QI) tools
3) ongoing: continuous monitoring of priorities
- strategic priorities
- performance measures
hierarchy of reducing errors
1) Strong action
- eliminate opportunity for error
- make it harder to do the wrong thing (simplify, standardise)
2) intermediate action
- make it easy to do the right thing (increase staff, reduce distraction, eliminate LASA)
- make errors more visible
- minimise injury
3) weak action
- policy, training, inspection
PDSA cycle
plan a change, do it in small test, study effect, act on results
culpability/incident decision tree
- builds Just culture by building practical approach to review issues associated with human errors
- culture of safety
** ability to speak up without concerns
** leaders openly acknowledge errors
** staff engagement at all levels
