Medication Errors 1 Flashcards
Guiding Principles (6)
Patient-Centred Healthcare
Patient Autonomy
Safe Healthcare
Leadership
Disclosure
Honesty and Transparency
Patient-centred Healthcare
Patient is front and centre
- Respectful, supportive, and takes into consideration the patient’s expectations and needs at all times
Patient Autonomy
Patients have a right to know information so that they can make decisions
Healthcare that is safe
Ensure quality assurance to increase patient care and outcomes
Leadership support
Leaders set up supports and resources to help deal with patient safety issues when they arise
Disclosure is the right thing to do
What would you expect in a similar situation
Honesty and transparency
Patient should be told what happened
- Important for patient’s trust and confidence in the healthcare system
Disclosure Process
- Preparation
Process should be defined in advance
- Panics and not knowing what to do can delay response
- Must be flexible to respond to patient specific scenarios
Disclosure Process
- Terminaology
Use Patient Safety Incident
- Errors has a bad connotation with it
Disclosure Process
- Kinds of Incidents
Did not reach the patient
- Near Miss / Close Calls (Should still be documented and looked into to prevent future cases)
Reached the Patient
- Harmful Incident
- No harm Incident (no injury, minor mistake)
Disclosure Process
- Stages
- Initial Disclosure
- Analysis
- Harm Results
Disclosure Process
- Initial Disclosure
Done ASAP by person who discovered incident
- An appropriate individual (pharmacist, not assistant)
- Not best practice to call insurance or head office first (leads to delays)
Disclosure Process
- Analysis
Avoid making assumptions
Should perform in-depth analysis
- What happened on our end
- What is the mistake
- Did the patient take the medication? How often? In what amount?
Disclosure Process
- Harm Results
- Natural Progression of medical condition (Consider ordering lab tests and procedures)
- Recognized risk inherent to investigations and treatment (Side Effects)
- System Failure (What could have led to a failure in judgement)
- Provider performance (Did the individual knowingly bypass protocols)
Saying Sorry
Part of the apology, viewed essential to the patient
- Use words like We or I
- Express genuine concern
- Non verbal cues are important
Words to avoid
Avoid legal words
- Fault
- Negligence
- Not meeting standard of care
Avoid assigning blame
- Only state facts known to date
Safety Culture
Just Culture
Reporting Culture
Learning Culture
Just Culture
- Definition
Blame is not focused on the individual but on the system instead
- NOT blame free, just more focused on accountable system
Just Culture
- Individual
Assess who was involved and what happened to lead to the error
- Impaired judgement? Substances?
- DId the individual intend for harm?
Was the individual involved with reckless activity
- Shortcuts? External pressure?
Just Culture
- Systems
Unintentional Error
- Occurs when everyone was following procedure without ill intent but the error still occurs
Reporting Culture
- Definition
Honestly report ALL Patient Safety Incidents (including near misses)
- Transparent
- Non-Punitive
- Leadership:
- Recognition:
Reporting Culture
- Transparent
Information is available to all team members
Reporting Culture
- Non-Punitive
No one will report if they are scared they will be punished
Reporting Culture
- Leadership
Needs to assure employes and not intimidate them (Expertise is held to higher value than role)
Reporting Culture
- Recognition
Recognize people who report incidents with praise and reward
Learning Culture
- Definition
Learning from the mistakes of others to better our current procedures
- Internal Review
- Communicate with Team Members
- Learn from Others
- Focus on Including Safety in all Aspects of the Operations
Learning Culture
- Internal Review
Not good enough to just report
- Must act, measure, and re-evaluate situations to ensure we know how to prevent future errors
Learning Culture
- Communicate with Team Members
Everyone should be aware of situations happening and what we are doing to prevent future errors
Learning Culture
- Learn from Others
Share information with others
- Voluntary or mandatory disclosure
Seek information
- From events and changes from others
Learning Culture
- Focus on Including Safety in all Aspects of the Operations
- What can go wrong
- What can we do to prevent it
