Incident Investigations and Systems Approach Flashcards

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1
Q

Illustrate healthcare as a complex sociotechnical system in terms of the following:

  • Culture
  • Policies
  • Goals
  • FInancial context
  • Legal context
A
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2
Q

Illustrate James Reason’s Swiss Cheese Model

A
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3
Q

Provide some examples of active failures

A
  • Slips and lapses
  • Violations
  • Mistakes
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4
Q

Provide some examples of latent conditions

A
  • Time pressures
  • Understaffing
  • Faulty equipment
  • Fatigue
  • Unworkable procedures
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5
Q

What is a systems approach?

A

A systems approach is a set of elements (people, processes, info, organisations, software, hardware, etc) that when combined have qualities that are not present in any of the elements themselves

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6
Q

Where should we apply a systems approach?

A

Systems approach to:

  • Incident investigations
  • Improvement following incident investigations
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7
Q

What is a root cause analysis?

A

A root cause analysis is a structured approach to the retrospective investigation of adverse events (usually SIs) in healthcare focusing on the identification of the underlying factors (latent) causing the problem(s)

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8
Q

A root cause analysis aims to answer 3 questions.

What are these?

A
  • What happened?
  • Why did it happen?
  • What can be done to prevent it from happening again?
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9
Q

What is a serious incident?

A

A serious incident is an event in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff/organisations are so significant, that they warrant using additional resources to mount a comprehensive response

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10
Q

There is no definitive list for never events.

However, provide some examples

A

Never events are acts and/or omissions that result in:

  • Unexpected/ avoidable death
  • Unexpected/ avoidable injury that leads or could have led to harm
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11
Q

Describe the process of incident reporting and investigation in the NHS

A
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12
Q

Account for the questionable quality of root cause analysis investigations

A
  • Difficulty in placing all the right people in the same room
  • Sources of varying quality
  • Non- participation
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13
Q

What are the sources of varying quality in root cause analysis investigations?

A
  • No black box
  • Medical notes / rotas / staff interviews and statements
  • Recall affected by hindsight bias
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