Patient Safety Flashcards
What are the 7 categories of DRP?
- Unnecessary drug therapy
- Need additional drug therapy
- Ineffective drug
- Dose too low
- Dose too high
- ADR
- Adherence
What is the harmonized system to classify DRPs?
IASE
- Indication
- Adherence
- Safety
- Efficacy
Describe the hierarchical approach to classify DRPs
- DRP categories:
- drug selection
- dosage regimen
- preparation and administration
- monitoring
- adherence and education
- operational (e.g., no original prescription, inappropriate storage condition, missing dosage regimen or signature, routine specialized counseling, request by patient, documentation of ADR into system, referral or update to HCP, illegible handwriting, removed expired/unnecessary medications)
- Actions taken to address IASE
- Process-related causes of the DRP (e.g., transcribing error)
- Types of medication errors
- Assessment and recommendations (documentation, SBAR)
What is the HFACS framework?
Human Factors Analysis and Classification System
What are the four levels of failures in the HFACS framework?
- Organizational influences
- Supervisory factors
- Preconditions for unsafe acts
- Unsafe acts
What constitutes organizational influences?
- Organizational climate
=> policies, culture, command structure - Operational Process
=> operations, procedures, oversights - Resource management
=> how human, monetary, and equipment resources necessary to carry out the vision are managed
What constitutes supervisory factors?
- Inadequate supervision
=> oversight and management of personnel and resources, including training, guidance, leadership etc. - Planned inappropriate operations
=> management and assignment of work including aspects of risk management, crew pairing, operational tempo, etc. - Failure to correct known problem
- Supervisory violation
What constitutes preconditions for unsafe acts?
- Situational factors
- Physical environment
- Tools/technology
- Personnel factors
- Communication, coordination, planning, teamwork
- Fitness for duty: rest requirements, alcohol restrictions
- Condition of operators
- Mental states
- Physiological states
- Physical/mental limitations
What constitutes unsafe acts?
- Errors
- decision errors “thinking”
- skill-based errors “doing”
- perceptual error: sensory input degraded (e.g., imperfect/incomplete information)
- Violations
- routine violations: habitual
- exceptional violations
Decision tree for unsafe acts culpability
What is the substitution test?
Given the culprit did not intend the actions, and did not knowingly violate safe operating procedures,
substitution test can be done to determine if it is likely an environmental problem or the individual is to be held accountable
If pass substitution test => blameless error
What are some recommendations for second victims?
- Participate in disclosure
- Seek help
- Participate in the incident review process and learn about any inadequacies identified
- Recognize that human errors happen to all practitioners
- Share your story
Five rights of a second victim: TRUST
Treatment that is just
Respect
Understanding and compassion
Supportive care
Transparency and opportunity to contribute to learning
What are some proactive implementing strategies?
- Enterprise risk management (ERM)
- Establish context
- Identify, Analyse, Evaluate, Treat Risks
- Clinical risk management
- SRI2: safety, risk, improvement and innovation
- Failure modes and effects analysis (FMEA)
- Identify failure modes and current control measures, conduct risk prioritization and criticality analysis, formulate and implement new control measures, conduct post-implementation review, document FMEA and monitor
What are some reactive implementing strategies?
- Incident management
- incident decision tree
- second victim
- medico-legal considerations
- disclosure
- Root cause analysis (may do indiv or aggregate)
- manage serious clinical incident
- manage errors with minor adverse outcomes
- manage errors/near-misses with no adverse outcome
- Problem solving
- e.g., long waiting times, operational inefficiency, error-prone processes
- Quality improvement tools
What are some ongoing implementing strategies?
- Strategic priorities
- What to focus on with finite resources?
- Guidelines, committees, collaborative
- Performance measures
