Human factors in patient safety Flashcards
Give 5 factors human factors for patient safety
Complacency Distraction Competence Communication Stress Fatigue Lack of assertiveness Lack of resources Leadership Situational awareness
2 models/theories to explain patient safety
Heinrich’s triangle theory (number of minor accidents is reduced then there will be a corresponding fall in the number of serious accidents)
Swiss Cheese model (many things bypass checks before there is a big slipup)
What are never events?
Events which cause harm or death to patients, which show gaps in the provision of care
Give 2 examples of never events
Surgery - Wrong site or implant/retained foreign object Medication - Wrong preparation, route, overdose Mental Health - Suicide General Healthcare - Fall from windows, entrapment in bed rails, misplaced NG tube, misidentification OBGYN - Death due to PPH
Who do you inform once a never event occurs?
CQC
National Reporting and Learning System
Examples of interventions to reduce never events, improve patient safety?
Behaviour change
Safety huddle
Simulation
Collaborative working
Culture surveys
What are the 2 approaches to improving patient safety? Which one is better?
Persons approach
Systems approach. This is better as does not promote cover up
Give 2 red flags for evolving error chains
Ambiguities Confusion Communication breakdown Missing information Departure from standard practice Fixation Time distortion Unease Alarm bells going off in mind/ warning sounds from machine
Examples of safety tools?
Surgical safety checklist
SBAR for handovers
Sloth error refers to not bothering to check results, what are some other types of error and give examples for each.
Which theory explains implicit and explicit trains of thought which can lead to errors?
Dual process theory
What is the effect called when members of the healthcare team just let a wrong behaviour take place?
Bystander effect
