Lecture 20

Question 1

Describe the traditional view of Safety

Answer 1

• Safety 1 = absence of accidents
• Focusses on when things go wrong
• What caused the failure
• How can we prevent the failure

Question 2

Describe the new view of Safety

Answer 2

• Focuses on understanding normal performance, variability, flexibility, and resilience
• Know that usually there are no mistakes but occasionally things go wrong

Question 3

What is an error of commission and give an example in health care context

Answer 3

Actions that should not have been done or was done incorrectly e.g. wrong dose

Question 4

What is an error of omission and give an example in health care context

Answer 4

Action that was not done e.g. missed diagnosis

Question 5

What do errors of omission and commission focus on?

Answer 5

What was done, not why it was done

Question 6

What is a violation defined as?

Answer 6

Deliberate deviations from ‘what one ought to do’ e.g. working over set hours

Question 7

What can an unintentional error caused by?

Answer 7

Cognitive failures

Question 8

What are the two types of unintentional errors?

Answer 8

1. Slips

2. Lapses

Question 9

Describe a ‘Slip’ and state what error type it is

Answer 9

• Unintended action therefor an error of commission

- e.g. wrong instructions given

Question 10

Describe ‘Lapses’ and state what error type it is

Answer 10

Unintended error of omission e.g. missed step in the procedure

Question 11

What is a mistake?

Answer 11

Actions are planned to be correct but don’t work out

Question 12

What are the different types of mistakes and describe each one?

Answer 12

1. Rule based = operator misapplies/doesn’t follow the rule
2. Knowledge based = operators knowledge of world is inadequate for them to take action
3. Skill based = (physical) skills are inadequate / inadequately applied

Question 13

Describe the use of Evaluating Error using Reason’s Taxonomy

Answer 13

• Errors are categorised using Reason’s taxonomy
• > knowledge based mistakes
• > rule based mistakes
• > skill based mistakes
• > technical error
• > system based problem
• Look at the mitigating factors
• Evaluate a strategy

Question 14

What is an Electronic Health Record?

Answer 14

A longitudinal record compiling all medical history and appointments

Question 15

What are the benefits of an Electronic Health Record?

Answer 15

• Comprehensive

- Standardised and accessible to collate population data/trends

Question 16

What are the negatives of an Electronic Health Record?

Answer 16

• Places more responsibility on the Dr
• Decreases interview flow and rapport
• People don’t know where their private info is being used