MSK 18 Flashcards
Medication error vs near miss?
An error goes to the patient but a near miss doesn’t
What is medication related harm?
When something caused by medicine like side effects
Why we report errors and near misses?
To understand what happened
Why it happened
To take positive action to prevent in future.
What is the name of log book to report error or a near miss in all DHB?
(SAC) severity assessment codes
What are the barriers of reporting errors and near misses?
Fear of retaliation
Lack of feedback
Ego
Workplace culture
What is open discloser is?
Right 6 all consumes the right to be fully informed
What are the points must have of An open discloser?
What happened How it happened Why it happened What actions taken A sincere apology\ Acknowledge the seriousness informed about how to contact the HDC
What is the requirement of HCP?
Help seeking behaviour
Recognition that human error happens
Share your story with your colleague
Create culture and safety of the organisation
What is Root causes analysis?
It is a systemic process for identifying root causes of problems or events and and an approach for responding to them.
By asking questions why what what reason.
What are the strategies to reduce risk of errors?
- Forcing functions
- Automation
- Standardisation
- Reminders
- Double check
How to do Quality improvement initiative?
Plan> do> Check> And Act
Where error can occur in health care system?
Paediatrics
Geriatrics
Pregnancy
