Human Factors in patient safety

Question 1

What are the never events?

Answer 1

• Cause harm or even death to patients
• Show gaps in the provision of healthcare
• Are published in National Quality Data
• Affect the reputation of the Trust, with patients, public and staff
• Have financial penalties
• Prompt visits by external agencies e.g. CQC, Monitor, Commissioners
• Surgery - e.g. wrong implant, wrong limb, retained foreign body
• Medication e.g. wrong preparation, route, dose, overdose etc.
• Mental Health e.g. suicide
• General healthcare - falls from windows, entrapment in bed rails, misplaced NG tube, misidentification etc.
• Maternity - death from PPH

Question 2

What is the largest human factor leading to medical errors?

Answer 2

Miscommunication (70%)

Question 3

What are RED FLAGS of evolving error chains?

Answer 3

• Ambiguities/conflicting info.
• Broken communication/inconclusive decisions
• Confusion/ loss of awareness/ uncertainties
• Missing information/ Incomplete briefing
• Deviating for standard procedures and normal practices
• Alarm bells in mind or warning signals from equipment
• Denial/Stress/Pressure

Question 4

When looking for the source of human error do they look at the individual, the incident or the system?

Answer 4

System rather than the incident or person (unless they then decide is not a problem of the system)

Question 5

What is the Conformity Problem?

Answer 5

The greater the benefits and lower the likely consequences, the more common it is for people to migrate towards working in ways that they know to be wrong or break the rules. Overtime these ways become the ‘norm’ and integrated into the workplace

Question 6

What are human factors which can compromise patient safety?

Answer 6

Teamwork
Fatigue
Leadership
Situational awareness
Lack of resources
Distraction
Lack of knowledge
Pressure, stress
Complacency
Communication ( or lack there of )
Lack of assertiveness

Question 7

What are examples of interventions to reduce the risk of human factor causes?

Answer 7

Behaviour change
Collaborative working
Safety huddles
Culture Surveys
Simulation

Question 8

Which conditions/issues are big issues with regard to failure of patient safety ? ( have the biggest consequence to the patient)

Answer 8

Sepsis
Deteriorating patient 
End of life care
AKI
Falls
Pressure ulcers