Patient safety Flashcards
Discuss terminology surrounding patient safety
Patient safety incident: An event that could have resulted in or did result in unnecessary harm to a patient
Reportable circumstance- as situation where there was significant protentional for harm but no incident occurred
Near miss- an incident which di not reach the patient
No harm - an event reached a patient but no discernible harm resulted
Adverse event
- also known as a harmful incident
- an incident that results in harm to patient
Harm
- an impairment of structure or function of the body and or any deleterious affect arising there from including disease injury suffering disability and death
- may be physical social or psychological
Contributing factor
- a circumstance action or influence (such as poor rostering or task allocation) that contributes to the origin or development of an incident or increase the risk of an incident
#may be
-external (not under the organisations control)
-organisational
-staff related (individual cognitive or behavioural issue, poor team work, inadequate communications)
-Patient related
Adverse drug reaction
-unexpected harm from a justified treatment
Adverse effect
- a known effect that is not what is primarily intended and related to a medicine pharmacological properties
Preventable
-considered as avoidable in the particular set of circumstances
Mitigating factors
- an action or circumstance that prevents or moderates the progression of an incident towards harming a patient when the mechanism by which damage may occur is already in train, but has not led to the max possible harm
Resilience
- the degree tow which a system continuously prevent detects mitigates or ameliorates hazard or incidents
Discuss fatigue and performance
16 hours of continuous work is equivalent to a blood alcohol concentration of 0.05%
-24 hours of wakefulness is equivalent to a blood alcohol concentration of 0.1%
Adverse event rates are much lower when shorter shifts are implemented (<12 hours)
Discuss principles of harm minimisation
Error is inevitable
- harm is not an inevitable consequence of error
- find out what is wrong not who is wrong
- the person who has made the error it he person
1) least likley to make it again
2) most likley to provide the solution
3) most likely to prevent others from making the same error
Discuss saftey monitoring
Incident reports
-used in only 2% of adverse events
Family reports
- in one study detected 5 x times more medical errors and 3x more AEs than the volunatary incident report system
- increased overall error detection by 15% and AE reporting by 10%
Complaints
- uncommon
- often related to interpersonal issues rather than processes
Mortality/morbidity reports
-too late for that patient
Review of sentinel cases/near missed
- more common
- may be effective
Routine chart review
- detects only 10% of actual medical erros
General performanace measures
Discuss mechanism to prevent harm
- Good leadership
- situational awareness
- open communications (team decision are generally better than individual ones)
- Checking (never assume anything)
- remove barriers to communications (especially hierachy effect)
- redundancy mechanisms
Describe hierachy effect
When a subordinate does not challenge a more seniour colleague even though they know the senior colleagye to be wrong
More common when
-the subordinate is in a vulnerable position
-the organisation is very hierarchical
-there is a major difference in experience/rank
-the seniour lacks humillity
Discuss graded assertiveness
It is team member responsibility to assert a corrective action in a firm and respectful manner
- make an opening
- state the concern
- suggest a solution
- obtain agreement
- If initial assertion is ignored make again to ensure taht it has been heard – if ignored again and outcome is still unacceptable take a stronger course of action
Graded assertiveness (pace)
Level 1: probe: “somethings not right”
Level 2: alert “maybe we should do something else”
Level 3: Challenge “why are we persisting”
Level 4: Emergency “ we are unsafe - DO something”
Levels of assertive language
- is everything alright
- it might be better if
- i think we should
- we should
- i am still not happy
- i think we need some help
- i think you should call them
- i will call them
- if you wont i will
Discuss clinical handover
High risk procedure – associated with 25% of adverse events
-Structured approach may improve communication to improve patient safety
Bedside handover is ideal
- introduces the patient to the next care giver
- enable patient input into the transfer
- updates the patient on their progress
- provides an opportuniaty for the receiving staff member to directly asses the patient
- may not be able to provide other features that maximise handover saftey
Discuss handover tools
Non proven to be superior
#ISBAR
-Identity of patient (Name, age, UR,)
-Situation (symptoms/problem, pateint stability and level of concern)
-Background ( History of presentation, date of admission and diagnosis, relevant pmhx)
-Assessment and action ( what is the diagnosis/impression, what have you done so far)
-Response/rationale (what you want done, treatment IX underway or taht need monitoring, review: by whom and for waht, plan)
-5 Ps
Discuss techniques to maximise saftey at handover
Reduce number of handovers
- decrease LOS
- shift overlap
- encourage staff to finish off problems
Limit disruption and interruptions during handover
Provide concise overview
-highlight outstanding tasks
-anticipate changes
-have a clear plan
-make information readily available for direct review
-encourage questioning and discussion of assessment
-account for all patients
-specify when transition of care occurs
Discuss individual factors that can contributed to adverse incidents
Usually multifactorial and involves deficits at multiple levels of the organisation
- Staff seniority
- staff training or prior experience
- decision making
- procedural skills
- exceeding limits of position
- communications/documentaiton
- pateitn specific factors ie: language difficulty
- hazardous attitudes
- —Impulsive or resigned
- —Invincible or fearful
- —Anti-authority or unquestioning
Discuss system factors that can contribute to adverse incidents
- Staff supervision
- education and training
- staff operating outside their role delineation (if so why)
- Confusion about responsibilites between teams
- supports - absence/ failure of
- Work load
- Work conditions e.g night shift
- multi tasking - e.g responsible for two areas at once
- consultations process e.g telephone advice from inpatient reg
Discuss management of patient saftey incident
Should be by senior staff
must address both clinical and non clinical issues
must manage patient, family and staff
invovles immediate response and follow-up action
Clinical issues
- provide immediate medical attention
- manage any complications
- involve appropriate senior staff
- arrange appropriate disposition and ongoing care
- notify staff providing ongoing care of the circumstances
- if identity error involved ensure taht a second patient is not harmed as well
Non clinical
- explain situation to patient and carers
- reassure where possible
- manage staff memebers
- document (event, management, notification)
- complete appropriate saftey system notification
Notifications for an ED incident
- senior ED staff
- receiving medical unit senior staff
- hospital administration
- clinical risk team
- medical defence
- other as required
Investigation consideration
- establish facts as soon as possible after the event
- individual vs system factos
- RCA
- hospital clinical risk unit investigation
- coronial investigation
- QI
Good communications with the patient and family following an adverse event strongly influences the actions of the patients (e.g complaint, litigation, no action)
Discuss open disclosure
Encouraged in all jurisdications in Australia – not currently a legal requirement
Benefits
-limited evidence that disclosure reduces the likelihood of litigation
-most health professionals feel a moral obligation to disclose
-meets ethical expectation for health professional in their practice
-allows patients to make autonomous decisions about thier care
0 meets the expectation of patients and thier families for disclosure after adverse events
-may lead to an improvement in the quality of services
-may ameliorate the -ve psychological consequence of the event for the patient
AIms
- reduce psychological harm to the patient
- help re-esatblish the patients trust in the service
- – it is crucial that you are open honest and can seen thigns from their perspective
Discuss an approach to open disclosure (12)
1) Inform the patient as soon as possible of the adverse event
- senior as possible staff member should do this
2) briefly establish the facts surrounding the event
- do not interrogate the patient at this time
- establish the facts in more detail later in the conversation or get someone else to do this if your actions may have led to the adverse incident
3) reply promptly to a letter of complaint
4) express sincere regret and concern for the patients welfare ( i am sorry this has happened to you)
- express regret on behalf of other involved
- do not admit liability prior to comprehensive investigation
- further analysis may lead to the conclusion there was no liability
- avoid drawing premature conclusion before investigation
5) acknowledge impact on patient
6) provide information about what actually happened
- only speak about what you know
- do now speculate about a cause a the time
- do not make excuses
- explain that multiple factors often contribute to advers event
7) explain the potential consequences of the event on them
8) explain the steps being taken to mininmise harm from the event
9) advise that
- a full investigation will occur to identify the reasons for the event
- the investigation will be independent of the people involved
- they will be advised of the outcome
10) explain the process of the investigation, key people and time frame
- formal reporting of the incident using the orgnisations saftey mangement system
- patient liason officer
- saftey and quality unit
- involvement of the ED director
- incident review panel(for more serious incidents)
11) validate the patients right to fell how they do
12) if a patient perception of the facts and your differ do not try to show taht you are right
