Negligence Flashcards
Define error
An unintended outcome
Define negligence?
Breech in duty of care resulting in damage
What are the two approaches in terms of errors?
Person approach: focus on individual who made the error
System approach: focus on the working conditions that led to the error
Tools of risk identification?
Incident reporting Complaints and claims Audit, service evaluation External accreditation Active measurement
Strategies to reduce errors and harm?
Simplification and standardisation of clinical processes
Checklists, aide memoires
IT
Team training
Risk management programmes
Mechanisms to improve uptake of evidence based practice
Define never event.
Give examples
Serious, largely preventable patient safety incidents that should not occur if measures are implemented
Wrong site of surgery, retained instrument
Medication: wrong, wrong route
Suicide in mental health facility
Define these errors:
Sloth Fixation + loss of perspective Communication breakdown Poor team working Playing the odds Bravado Ignorance Mis-triage Lack of skill System error
Sloth: laziness, not checking results
Fix + LOP: unshakeable fixation on diagnosis and not looking at bigger picture
CB: unclear instructions, not listening to others
PTW: working independently, some out of depth, others underutilised
Odds: choosing common conditions over rare
Bravade: working beyond competence
Ignorace: not knowing what you don’t know
Mis-tr: Over/underestimating seriousness
Lack of skill
System error: IT or equipment error
What’s the swiss cheese model.
Holes represent weaknesses in system
If all holes align this permits a trajectory of accident opportunity, so then a mistake can occur
What’s the criteria for negligence?
Was there a duty of care
Was there a breech in duty
Did the patient come to any harm?
Did the breech cause the harm?
What are some causes of human error?
Stressful environment Distractions Compliancy Tiredness, hunger Emotional upset
What are bolam and Bolitho rule?
Bolam: would a reasonable doctor do the same?
Bolitho: would that be reasonable
Name of these rules?
- would a reasonable doctor do the same?
- would that be reasonable?
Bolam
Bolitho
Describe the bucket model?
There are three buckets:
- self
- context
- task
The fuller each bucket is the more likely a healthcare professional is to commit an error and harm results.
What would be in each of the buckets in the bucket model?
Self:
- lack of knowledge
- fatigue
- negative life events
Context / environment:
- distractions
- lack of time
- poor equipment
Task:
- complexity
- new task
- process that’s involved
Who should you report a never event to?
GMC
CQC
