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
notifibale pt safety incident
unintentned or unexpeted notifiable safety incident
> mod or severe haem
mod inc in t
prolonged psychological harm or deah
conflict resoluxn techs
like 5 dice shape
on graph i get what i want on y axis = assertivemness
you get what u want - cooperativeness x axis
aggrexn = top l
move horixontal =
collaborate
compromise
avoid
accomodate
pt safety uncident d
unintended injury caused by mecdical amamgements rathertrhan dis itseld
safety 1
understanding why
modes of working linked to advser outfcofmfes
wajt’ve we done to causes this failurte
find + fix
safery 2
reflect that in complexitu + uncertianty
most o time things fo right
docus on what work well
cascade this
why apply human facors
understand why healthcare staff make errors
which system factrors threatedn pt sagety
mp safety culuter of teams+ organsians
enhave teamwork
improve communicaxn between healthare staf
imp design of healthcare sys + equip
identify what ehn wrong
oreguct what could go wrong
aprecate who certain ttols mentioned can essen likelihoos of pt harm
cassify hf
Environmental
• Organisational
• Job factors
• Individual characteristics - human fallibilit
context
Environment • NHS a myriad of different set ups • Resources • Equipment • Staffing, numbers/grad
task
• Doing the job • What you do • What others do (team) e.g. checking medicines correctly
