Fundamentals Flashcards
Teams in the NHS
Tradition in certain areas eg operating theatres
Community care and GP teams
NHS plan
Service reconfigurations
Why are teams important
Efficient
Improves decision making
Reduces medical error
Essential in complex, modern healthcare
What percentage of medical errors are due to breakdowns in teamwork
70%
A good healthcare team
Clear roles and understanding of each team member’s role
Mutual awareness of team member’s role
Knowledge sharing
Effective communication
Shared goals
Mutual respect and trust
Positive attitude
7 steps to patient safety
Build a safety culture
Lead and support staff
Integrate your risk management activity
Promote reporting
Involve and communicate with patients and public
Learn and share safety lessons
Implement solutions to prevent harm
Problems with teams in NHS
Healthcare teams are not all the same
Delivered by individuals from different professions
Medics often seen as outliers
Difficult to monitor
Obstacles to teams in the NHS
Environmental barriers:
Organisational- shifts/rotations
Location
Management
Other commitments of team members and professional specific goals
Complex leadership
SBAR communication checklist
Situation
Background
Assessment
Recommendation
Error
Any preventable event that may cause or lead patient harm
Types of human error
Errors of omission
Errors of commission
Professional negligence
Skill based errors
Rule/knowledge based
Errors of omission
Required action is delayed or not taken
Errors of commission
Wrong action taken
Professional negligence
Actions or omissions do not meet the standards of an ordinary, skilled professional who has competence
Skill based errors
Mistakes during routine tasks due to poor concentration/distraction
Rule/knowledge based errors
Inexperience leading to incorrect course of action, often in complex tasks
2 outcomes of medical errors
Adverse event
Near miss
Near miss
An event during care which has potential to cause harm but fails to develop
Adverse event
Incident that results in harm to a patient , not a result of illness
Violations
Deliberate deviations from practices, procedures, standards or rules
Types of violations
Routine
Necessary
Optimising
What are violations due to
Attitudes, motivations , contextual influences rather than cognitive limitations
Information processing limitations
Automaticity
Cognitive interference
Selective attention
Cognitive biases
Transferring expectations
Automaticity
Doing tasks without thinking
Cognitive interference
More complex task requires higher demand
Selective attention
Limited additional resources
Information overload
Cognitive biases
Effects of long term memory and previous exoerienes
Transferring expectations
Positive or negative
From familiar objects.situations to similar new ones
Approaches to managing error
Person
System
Person approach to managing error
Focuses on the unsafe acts of professionals
Shortcomings of person approach to managing error
Anticipation of blame promotes cover up
No way of uncovering repeated errors
Relies on trust in reporting errors
System approach to managing error
adverse events are products of many causal factors
Efforts are directed at removing error traps and strengthening defences
Latent conditions
Lie dormant within the system before they combine with active failures and local triggers to create an accident opportunity, can be identified and remedied
Active failure
Hard to foresee
Reducing error and harm
Simplification and standardisation of clinical practices
Checklists and aide memoire
IT and softeware
Team training
Risk management programmes
Mechanisms to improve uptake of evidence based treatment patterns
Tips for junior doctors when reducing errors
Develop internal alarm bells
Seek help when overwhelmed
Use clinical guidelines
Always document thought process, actions and plans
Checking results and recorded information
Speaking up if an error is suspected
Why is safety compromised so often
Complex, high risk environment especially in hospitals
Resource intensive
Often shared responsibilities
Ethics - Richard Norman 1998
Attempt to arrive at an understanding of the nature of human values
How we ought to live and what constitutes right conduct
Ethical arguments
Top down deductive
Bottom up inductive
Top down deductive
Where one specific ethical theory is consistently applied to each problem
Bottom up inductive
Using past medical problems to create guides to practice
Morality
Concern with distinction between good and evil, right and wrong (universal)
Ethics
A system of moral principles and a branch of philosophy
Defines what is good for individuals and society
Differs in different cultures
Doctrine of dual effect
Harmful effect is inseparable from the good effect
Nature of act is good and intention is good
Good effect outweighs the bad effect
Meta-ethics
Nature of ethics and moral reasoning
Exploring fundamental questions
Right/wrong defining the good life
Normative ethics
Determining the content of our moral behaviour
Focus is on the act itself, the person performing it and its consequences
Applied ethics
Attempting to deal with the specific realms of human action, crafting criteria for discussing issues
Emergence of ethical investigation in specific areas
Environmental, medical and public health
