Lesson 2 (Part 2)

Question 1

What are 2 ways we can handle human errors?

Answer 1

1. Person approach

2. Systems approach

Question 2

What is the person approach? (3)

Answer 2

1. Blame and shame
2. Assumption that error is due to laziness, forgetfulness, negligence, lack of knowledge, skill or experience
3. Punishment to eliminate error repetition

Question 3

Which is the best approach when dealing with human errors?

Answer 3

The systems approach

Question 4

Why is the systems approach the best approach when dealing with human errors?

Answer 4

Because people are less likely to come forward and the mistake will never get fixed

Question 5

Systems approach (4)

Answer 5

1. Acknowledgement that humans are fallible by nature
2. Anticipates human errors
3. Designs systems to decrease the risk of an error occurrence
4. Focuses on latent failures as opposed to active failures

Question 6

What are 2 examples of a systems approach?

Answer 6

1. Monitoring machines change audio pitch if something is not normal
   - better chance for detection
2. Are you sure you want to delete button
   - there in case you accidentally hit delete

Question 7

Latent failures

Answer 7

Refers to less apparent failures in the design of an organizational system, the environment, or equipment that are often hidden until they contribute to the occurrence of errors or allow errors to go unrecognized until they harm patients

Question 8

Active failures

Answer 8

Are errors and violations having immediate negative results and are usually caused by an individual

Question 9

What are latent failures caused by?

Answer 9

Active failures

Question 10

What are some patient safety issues? (6)

Answer 10

1. Root cause analysis
2. Failure mode and effects analysis
3. Incident reporting system
4. Internal audits
5. Safety briefings
6. Complaint management system

Question 11

Root caused analysis

Answer 11

System based review of incidents to identify contributory factors in order to develop strategies to reduce the risk of recurrence
- review what happened and see how we can reduce factors of it happening again

Question 12

What is an example of root caused analysis?

Answer 12

Left something inside a patient

- solution = count to make sure everything is there so it doesn’t occur again

Question 13

Failure mode and effects analysis

Answer 13

Proactive technique that anticipates failures and deals with them before they occur, rather than reacting afterwards
- how to prevent a problem form occurring

Question 14

Incident reporting system

Answer 14

The documentation of actual or potential incidents in order to learn from our mistakes

Question 15

Internal audits

Answer 15

Periodic assessment of systems, processes and patient care outcomes
- ask around to see what works and what doesn’t

Question 16

Safety briefings

Answer 16

Daily briefings among staff to share concerns about potential issues

Question 17

Compliant management system

Answer 17

A way for patients to have their concerns dealt with efficiently and effectively

Question 18

When do you file an incident report?

Answer 18

Whenever an unexpected event occurs or could have potentially occurred

Question 19

What are examples of when to write an incident report? (4)

Answer 19

1. A patient complaint
2. Medication error
3. Medical device malfunctions
4. Someone is injured or involved in a situation where there was a potential for injury

Question 20

Why bother writing an incident report? (4)

Answer 20

1. A method of learning from past errors
   - teaching opportunity
2. To jog your memory
   - in case you have to go to court
3. To trigger a rapid response
   - induce policy change
4. It’s in your job description and is your duty

Question 21

What happens if you fail to write an incident report when needed to?

Answer 21

Can lead to termination and expose you to liability

- especially in cases where someone was injured or harmed in any way

Question 22

What do you include in an incident report? (6)

Answer 22

1. Date/time/location
2. Events leading up to the incident
   - what happens right before the incident
3. First hand information
4. Second hand information
   - needs to be written in quotes
5. Names of all those involved and how they were affected
6. The response to the incident

Question 23

What is first hand information?

Answer 23

What did you see or hear specifically

- you need to be specific

Question 24

What is second hand information?

Answer 24

Who is this information from

- are they a patient, colleague or visitor

Question 25

What are 2 examples of a response to the incident?

Answer 25

1. Call for help

2. Treatment for the injury

Question 26

What do you not include in an incident report? (6)

Answer 26

1. Abbreviations
2. Your opinions
3. Blame/speculation on who caused the incident
4. Proposed preventive measures
5. Hearsay
6. Dont try and match the report of your colleagues

Question 27

Hearsay

Answer 27

Information received from other people that one cannot adequately substantiate
- rumours