ICM - Critical Incidents

Question 1

What is a patient safety incident

Answer 1

Any healthcare event that is:
Unexpected
Unintended
Undesired
Associated with acutal OR potential harm

Question 2

Why are critically ill patients at greater risk for never events

Answer 2

High invasive treatments with complications
Frequent interventions
Freqent and many drugs and infusions
No capacity/autonomy
Lack of physiological reserve
Cannot communicate concerns
Busy/crowded

Question 3

Stages of delivering a medication

Answer 3

Prescription
Transcription
Prepare
Dispense
Admin (most errors are here)

Question 4

What is a medical error

Answer 4

Any mistake in the prescription
Preparation
Admin Of a drug
Does not neeccessarily cause harm.

Question 5

What is an Adverse Drug Event

Answer 5

A medication error with harm occurs

Question 6

Why are medication errors common on ICU

Answer 6

Patient - Severe illnes, extremes of age, prolonged hospital stay, sedated and lacking capacity, polypharmacy, changes to pharmacodynamics/kinetcs

Environment - patient and staff turnover, stress conditions, emergencys, communication issues

Medicine - many, pumps, infusions, weight estimation

Question 7

What is a never event

Answer 7

Serious incident…Wholly preventable….As there is guidance or safety recommendations
That provide strong and systemic barriers
Available at the national level
And SHOULD have been implemented by all heathcare providers

Question 8

Name never events

Answer 8

Surgical
- Wrong site
- Wrong implant/prosthesis
- Retained foreign body post op

Medication
- Wrong potassium solution
- Wrong route of admin
- Insulin oversdose
- wrong device, use of abbreviation
- Methotrexate overdose (non cancer)
- Mis-selected high strength midaz for concious sedation

Mental heath
- failure to instal collapsible shower/curtain rails

General
- fall from window
- chest/neck trapped in bed rails
- ABO incompatible transfusion
- NG tube misplacement
- Scalds

Question 9

What can help prevent/minimise a never event

Answer 9

1) two person checks of blood/drugs/STOP before you block
2) Barcode scanners
3) Checklists, WHO, etc
4) debriefs
5) standardised process, LOCSIP, NATSIP
6) team traning and awareness of human factors
7) manadatory training
8) culture of open communication

Question 10

Principles of the National Patient Safety Agency (NPSA) NG guidance

Answer 10

1) NOTHING should go down an NG until position confirms
2) First line - pH. 1 to 5.5.
Test strip must provide clear dilneation between 5.5 and 6
Document pH
NO LITMUS
3) second line. CXR - no aspirate or pH not in range
Who ordered/authorised xray
who confirmed position
check its right xray, most recent

Question 11

What happens if you have a never event

Answer 11

1) IT NEEDS TO BE REPORTED
2) maintain patient safety, stabilise the patient, and treat complications
3) Tell responsible consultant and head of dept
4) Candour, tell patient and family ASAP
5) Incident form Report on the Strategic Executive Infor System
6) tell relevent commisioner as per Serious Incident Framework
7) investigate, and do an Root Cause Analysis
8) Declare on Form R.