last lecture Flashcards
james reason profexn
psychologist
james reason designes which mod
swiss cheese
factors which contribute to latent holes in the Swiss Cheese Model
provider = training
distraxns
fatigue
team = shifting reponsabiliitiies
handovers
technical = poor desings
deferred maintenance
organixaxn =
culture
incomplte policies
funding + resouces
never events d
seriours
preventable
shouldnt occur
if prevnetative measure in palce
way stop never events happening
checklists
protocols
communicaxn
critical lens
self = indiv
context task
self issues
My personality • My Belbin role • My ability to challenge • Stress • Fatigue • Tiredness • Hierarchy – role – culture
na being aware of environ
situaxn awareness
self huamn factors acronym
IMSAFE = Illness, Medication, Stress,
Alcohol, Fatigue, Emotion
HALT = Hungry, Angry, Late, Tired
say sorry when thigs go wrong under which statutaory legislaxn
duty of candour
task human factors
- I’ve always done this before- self-belief
- Can there be a first time?
- Complicit
- Rules/ Policies/ Check lists/procedures
- With others
- communication
context human facores
- Team working concerns
- Respect and culture one to another
- Situational awareness – tunnel vision
- Pressure
- Systems
envrion stitua awareness
Innate ability to protect ourselves
• Heightened sense of awareness
• Observational skills
• Outside of self focus
personal situ awar
Intuitive
• Psychological
• Physiological
3 buckets
self context task
fuller buckets, more likley smg go wrong
b buckets never empty
pt safety divisn
from bottom to top
pts
staff= harm abosrbeerbs
factors in healthcare sys may > harm : pep equip tasl workspavce environ org
origins of qaluity improve lie outside healthcare >
yes
pdsa stand for
plan do study act
confirmaxn bias
attenxn to data that support oresumed diag
misnimise data contradict it
huamn facotrs d
enhave clinicla erformance
thru understanding eff teamwork tasks equip workspace culture org
on human behvaour + abilities
+ applicaxn of jnoeledge inc linical settings
pdsa cycle 1 step at a tome or all at once
1 step
bc if make lots changes at same time dont knw what dif changes made
min no of data pts for base line
20
duty of candour
contracuultal + statitory requiremneted to
provife pat + other rlelveant person
all necessary support
+ all relveant info ‘
if notifibale pt safety incident
when plotting data difs in data regerred to as
variaxn
