Patient harm, patient safety & Never event list Flashcards
Define patient harm
Unanticipated & unforeseen accidents which are caused by the direct result of the care given to patient, rather than their underlying disease.”
- e.g. patient falling from bed and fracturing neck.
Explain the different ways patients may come to harm?
- Medication errors
- Unsafe surgical care procedures
- Infections
- Systemic failures
- Human interaction
- Environment
- Equipment
- Personal (including negligence)
- Misdiagnosis
- Delayed Diagnosis
How can the risk of harm be reduced?
- Ensure incidences are properly reported, recorded & learnt from
- Appropriate measures to prevent future harm are put in place) - Avoid blame culture but ensure individual health professionals are required to be accountable for their actions (maintaining competence and practice ethically)
- Support each other, Be open & learn from event - Practice evidence-based medicine
- Learn how to apply evidence, Look for guidelines/ protocols in clinical settings & think whether they are best practice or not - Maintain Continuity of Care: Handovers/ change of shifts/ referrals
- Act Ethically- Opportunity to interview, examine, & treat patients is a privilege, Stay within competencies
- Adequate & appropriate staff training
- ### Systemic change:
- Organisations should routinely examine systems including equipment design, procedures & training
What causes medication errors? How to reduce them?
Caused by clinicians giving the wrong drug, dose, route of administration, patient or time.
Strategies to reduce this:
- Focus on training & professional development
- Clinical computer systems
- Confirm name & DOB
How to reduce harm associated with unsafe surgical care procedures?
WHO surgical safety checklist -a patient safety communication tool used to discuss key details about each patient’s surgical case.
Getting 2 people to check details
What causes the harm associated with infections? How to prevent this?
Hospital aquired infections e.g. Clostridium difficile.
Clinicians unable to identify the cause of an infection in a patient such as sepsis.
Preventable measures include:
- Strong emphasis on the hand washing technique to reduce the risk of hospital-acquired infections.
- The basic clinical observations & a National Early Warning Score (NEWS2) are essential in determining the clinical deterioration in acutely ill patients.
How does harm due to system failures occur? How to reduce the risk?
Healthcare professionals not knowing the standard operating procedures (SOP), care pathways or guidelines.
To reduce this risk:
- Staff members should have easy access to the policies at their workplace.
- Concise policies.
How does harm due to human interactions occur? How to reduce this?
Issues surrounding lack of communication, teamwork, decision making & leadership between various HCP & patients.
Can be resolved by:
- Handover meetings
- Improvement meetings - having discussions w/ colleagues then formulate plans to improve on these weaknesses.
-NHS programmes - e.g. Leadership development or the NHS Engagement & Communications Development Programme.
How does harm due to the environment occur? How to reduce this?
Static factors e.g. temperature, lighting, cleanliness, distance to toilets or resource location.
Dynamic factors e.g. interruptions during consultations or location changes.
Factors can be avoided by:
- Checking the surroundings first before patients enter the ward or to the consultation room.
How does harm due to equipment occur? How to reduce this?
Not familiar in using equipment.
Equipment not being cleaned thoroughly, then used on a patient, will spread infection.
Harm can be avoided through:
- Training & frequent use of equipment to ensure clinicians are familiar in using them onto patients.
- Equipment must be sterilised after every use.
How does harm due to personal reasons occur? How to reduce this?
Clinician might not be in the right state of mind.
Physiological reasons e.g. doctor may be unwell, tired, hungry or thirsty.
External influences e.g. time constraints, high workload or shift pattern.
This can happen to any doctor:
- Look after your mental health through speaking to their GP, talking to their seniors for advice or even contact the NHS Practitioner Health.
- Look after your well being by taking breaks, exercising & eating properly.
What is patient safety?
- The prevention of avoidable harm- whether by error (doing the wrong thing) or by omission (failure to do the right thing).
- e.g. giving wrong drugs; poor communication; not checking allergies.
- Often a system faliure - a “chain of events”
What is the never event list & why was it developed?
Events that should never be allowed to happen.
- Mistakes that keep happening.
- e.g. Potassium can stop the heart. It comes in vials that look very similar to water. Overdosing on potassium can kill so we need to change the design of the vials to stop the mix ups.
The list was developed to:
- Promote the implementation of preventative
- Allow for easy reporting of serious incidents.
- To increase awareness of these events in the workforce.
- i.e. if you know which events keep happening but should never happen, you can put procedures in place to change what your doing
Give some examples from the never event list.
- Wrong site surgery
- Retained foreign object post procedure.
- Administration of medication by the wrong route
- Placement of the wrong implant or prothesis
- Transfusion or transplantation of ABO-incompatible blood components.
- Nasogastric tubes - if it goes into the trachea the feeding tube ends up in the lungs!! Can cause aspiration pneumonia = death.
How is patient safety maintained in hospital when they are admitted for an operation?
- Wrist bands
- consent
- Marking of site
- labelling meds
- Allergies
- Sign out
- Post op care plan
