human factors and pt safety Flashcards
3 areas of lessons from civil aviation incidents to bring into clinical practice to maximise pt safety
operational
organisational
human
operational factors in pt safety
non techical skills
incident reporting
organisational factors in pt safety
system factors
standardisation
human factors in pt safety
perception, cognition, affect, psychomotor
impact of context
non technical skills include
4
Task management
* Planning, prioritising, standards, resources
Team working
* Co-ordinating individuals, information exchange, authority, assessing capabilities, support
Situation awareness
* Monitoring, recognising, anticipating
Decision making
* Identifying options, balancing risks, re-evaluating
70% of adverse events in hospitals are non-technical
benefit of incidents reports
Increased incidents reported so recognise risks that can be avoided in future
70% of adverse events in hospitals are non-technical
adverse events that should be recorded
all
- Unforeseeable patient death
- Preventable error leading to patient death
- Error leading to significant harm
- Error leading minor harm
- Error leading to no harm
- Error corrected before reaching patient = near miss / near hit
SBAR briefing model
Situation what the situation is
Background how we got to this point
Assessment what we know/think
Recommendation what are we going to do
common sources of risk
- Workload fluctuations
- Interruptions
- Fatigue
- Multi-tasking
- Failure to follow-up
- Not following protocol
- Poor hand-over of care between staff
- Ineffective communication
- Unfamiliarity with the task
- Inexperience
- Shortage of time
- Inadequate checking
- Poor procedures
- Poor human/equipment interface
human factors inc
- Affect (emotion interfering)
- Perception – based on context
- Cognition
- Memory
- Motor activity
- Involuntary automaticity
- Stress (mental, physical, emotional)
- Overload
