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chdd > last lecture > Flashcards

last lecture Flashcards

1
Q

james reason profexn

A

psychologist

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2
Q

james reason designes which mod

A

swiss cheese

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3
Q

factors which contribute to latent holes in the Swiss Cheese Model

A

provider = training
distraxns
fatigue

team = shifting reponsabiliitiies
handovers

technical = poor desings
deferred maintenance

organixaxn =
culture
incomplte policies

funding + resouces

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4
Q

never events d

A

seriours

preventable

shouldnt occur

if prevnetative measure in palce

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5
Q

way stop never events happening

A

checklists

protocols

communicaxn

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6
Q

critical lens

A

self = indiv

context task

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7
Q

self issues

A 
My personality
• My Belbin role
• My ability to challenge
• Stress
• Fatigue
• Tiredness
• Hierarchy – role – culture
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8
Q

na being aware of environ

A

situaxn awareness

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9
Q

self huamn factors acronym

A

IMSAFE = Illness, Medication, Stress,
Alcohol, Fatigue, Emotion
HALT = Hungry, Angry, Late, Tired

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10
Q

say sorry when thigs go wrong under which statutaory legislaxn

A

duty of candour

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11
Q

task human factors

A
  • I’ve always done this before- self-belief
  • Can there be a first time?
  • Complicit
  • Rules/ Policies/ Check lists/procedures
  • With others
  • communication
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12
Q

context human facores

A
  • Team working concerns
  • Respect and culture one to another
  • Situational awareness – tunnel vision
  • Pressure
  • Systems
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13
Q

envrion stitua awareness

A

Innate ability to protect ourselves
• Heightened sense of awareness
• Observational skills
• Outside of self focus

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14
Q

personal situ awar

A

Intuitive
• Psychological
• Physiological

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15
Q

3 buckets

A

self context task

fuller buckets, more likley smg go wrong

b buckets never empty

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16
Q

pt safety divisn

A

from bottom to top

pts

staff= harm abosrbeerbs

factors in healthcare sys may > harm :
pep 
equip
tasl
workspavce
environ 
org
17
Q

origins of qaluity improve lie outside healthcare >

A

yes

18
Q

pdsa stand for

A

plan do study act

19
Q

confirmaxn bias

A

attenxn to data that support oresumed diag

misnimise data contradict it

20
Q

huamn facotrs d

A

enhave clinicla erformance

thru understanding eff teamwork 
tasks 
equip 
workspace 
culture 
org

on human behvaour + abilities

+ applicaxn of jnoeledge inc linical settings

21
Q

pdsa cycle 1 step at a tome or all at once

A

1 step

bc if make lots changes at same time dont knw what dif changes made

22
Q

min no of data pts for base line

A

20

23
Q

duty of candour

A

contracuultal + statitory requiremneted to

provife pat + other rlelveant person

all necessary support

+ all relveant info ‘

if notifibale pt safety incident

24
Q

when plotting data difs in data regerred to as

A

variaxn

25
Q

notifibale pt safety incident

A

unintentned or unexpeted notifiable safety incident

> mod or severe haem

mod inc in t

prolonged psychological harm or deah

26
Q

conflict resoluxn techs

A

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

27
Q

pt safety uncident d

A

unintended injury caused by mecdical amamgements rathertrhan dis itseld

28
Q

safety 1

A

understanding why

modes of working linked to advser outfcofmfes

wajt’ve we done to causes this failurte

find + fix

29
Q

safery 2

A

reflect that in complexitu + uncertianty

most o time things fo right

docus on what work well

cascade this

30
Q

why apply human facors

A

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

31
Q

cassify hf

A

Environmental
• Organisational
• Job factors
• Individual characteristics - human fallibilit

32
Q

context

A 
Environment
• NHS a myriad of different 
set ups
• Resources
• Equipment
• Staffing, numbers/grad
33
Q

task

A 
• Doing the job
• What you do
• What others do (team)
e.g. checking medicines 
correctly

chdd (12 decks)

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