medication therapy Flashcards
cognitive approach
- mental process
- thinking , memory, judgement
3 levels of human performance
Reason’s Generic Error Modelling System (GEMS)
- skill
- rule
- knowledge
what errors occurs at skill based
Very familiar tasks
No conscious thought
Problems occur when there is a lack of attentional checks:
Intention to depart from customary activity
Interruption
Delay in carrying out activity
Look-alike objects
Conducting 2 or more tasks concurrently
Slips: performing the wrong function
attentional failure
Lapses: forgetting to perform a task
memory failure
what errors occurs at ruled based
Familiar task but not yet skilled
Conscious decision to follow a series of tasks
Selecting the wrong rules…
Mistakes
what errors can occur at knowledge based
Unfamiliar task
Conscious actions carefully thought through
No “rules” to match it
High concentration level
Limited information can be received and interpreted
Mistakes
misinterpretation of environment & inability to perceive and process all necessary information at once
what is violation error
Intentional deviations from guidelines or norms of behaviour
can be beneficial or harmful
Human and error:
the perfection myth
If we try hard enough we will not make any errors
human and error
the punishment myth:
If we punish people when the may errors they will make fewer of them
what is a system
“A set of inter-related activities or entities (hardware, software, buildings, spaces, communities, people) with a joint purpose”
Dul et al. 2012.
They are linked and so will impact one another
Boundaries
systems exists within boundaries (physical, service) with inputs and outputs, ‘whole is greater than the sum of its parts’
micro, meso, macro
what are individual factors which can cause errors
Individual factors Tired Hungry Unfamiliar with task No self-check procedure Unfamiliar with formulations Performance deficit
what are task factor errors
Interruptions
Similar drugs adjacent
Drop down lists
Unavailable protocols
what are team factors which can cause error
Team factors Poor handwriting Ambiguous directions Lack of experience Reluctance to seek help Asymmetric relationships
what are work environment errors
Work environment Insufficient staffing levels Staff unfamiliar with dispensary Heavy workloads Lack of space Similar packaging and drug names Dispensary design
person vs system approach
Person approach
Individuals who make errors are ‘careless, at fault, reckless’
Blame and punish
Remove individual = improve safety
Systems approach
Poor organizational design sets people up to fail
Focus on the system rather than the individual
Change the system = improve safety
Need to get the balance right
Both extremes have their pitfalls
A JUST CULTURE
micro-system
meso-system
macro-system
micro system - tools
meso system - people, tools, spaces
macro system - people , building, communities, spaces, hardware, tools
