Patient Safety

Question 1

What are human factors?

Answer 1

‘All the things that influence human beings affecting how well [they] do any task’

Question 2

What are human factors that can increase risk to patient safety?

Answer 2

Mental workload (the knowledge isn’t embedded or the problem is complex)

Distractions

Physical environment (too hot or cold)

Physical demands (eg long shifts)

Device/product design (lack of familiarity or difficult to use)

Teamwork (tensions in the team, poor communication)

Process design (too many steps, or not well integrated into other daily tasks)

Question 3

What is ‘cognitive load’?

Answer 3

“Cognitive load” relates to the amount of information that working memory can hold at one time.

Question 4

What is the ‘swiss cheese model’?

Answer 4

An organisation’s defences against failure are modelled as a series of barriers, represented as slices of cheese. The holes in the slices represent weaknesses in individual parts of the system and are continually varying in size and position across the slices.

Question 5

What is the ‘three bucket model’?

Answer 5

Assesses risky situations:

1) Self
2) Context
3) Task

The fuller your bucket, the more likely something will go wrong. But your buckets are never empty.

Question 6

Examples of ‘self’ bucket?

Answer 6

• Level of knowledge
• Level of skill
• Current capacity to do task (e.g. tired, ill)

Question 7

Example of ‘context’ bucket?

Answer 7

• Equipment
• Physical environment
• Workspace
• Team and support
• Organisation and management

Question 8

Example of ‘task’ bucket?

Answer 8

• Errors
• Task complexity
• Process

Question 9

What is open loop thinking?

Answer 9

Leads to progress because feedback from failure is rationally acted upon:
- Failures are recognised and acknowledged

Question 10

What is closed loop thinking?

Answer 10

Failure doesn’t lead to progress because information on errors and weaknesses is misinterpreted or ignored

Question 11

What is system 1 thinking?

Answer 11

Fast, Intuitive, Emotional (gut feeling, first impressions). Pattern recognition and prior experience help inform it. Often ignoring absent information: ‘What You See is All there Is’.

Question 12

What is system 2 thinking?

Answer 12

Slow, deliberative, logical and takes MORE ENGERY (reflection, problem-solving, analysis). Informed by System 1 and over time can develop into deep values or beliefs.

Question 13

When would you typically use system 1 and 2 thinking?

Answer 13

We spend most our time in System 1, we couldn’t function if we didn’t. It runs ‘automatically’ in the background.

System 2 gets involved when we encounter something unexpected or that System 1 can’t automatically process.

Question 14

What is a SEA?

Answer 14

Significant Event Analysis.

Can be used to analyse positive or negative events where patient outcomes were affected or ‘near misses’ where an error may have led to harm, but was caught in time.

Question 15

What is a SUI?

Answer 15

SUI = Significant Untoward Incident.

These are usually defined by a major event (such as an unexpected death) or where a patient has suffered significant harm as a result of treatment or lack of treatment.

Question 16

What is a ‘never event’?

Answer 16

Incidents that require investigation under the Serious Incident Framework.Defined as serious incidents that are wholly preventable because guidance or safety recommendations are available and should have been implemented.

Eg. Wrong site surgery

Question 17

What is the ‘yellow card scheme’?

Answer 17

Anyone can report medication side effects (including homeopathic or herbal remedies), incidents involving defective devices, defective medicines, or suspected falsified or fake medicines or devices.

Question 18

What is the importance of surgical checklists?

Answer 18

At least half of the cases in which surgery led to harm are considered preventable

Reduced mortality. Improved patient safety. Helps to flatten hierarchy and improve communication.

Takes about 2 mins

Question 19

What is the acronym PACE?

Answer 19

Probe, Alert, Challenge, Emergency

Question 20

What did the ‘Think Sepsis’ campaign give rise to?

Answer 20

National early warning score (NEWS) which helps to aid communication to call handlers and other clinical staff about the urgency of a case of suspected sepsis.

Processes that enable early identification and communication of risk lead to improved clinical outcomes.

Question 21

How can the portrayal of mistakes affect future errors?

Answer 21

A working culture that views mistakes, failures or ‘near misses’ as learning opportunities will result in staff feeling more able to speak out and will REDUCE the incidence of future errors.

Question 22

How does the blame approach affect future errors?

Answer 22

Strict managerial style accompanied by a blame approach to error does not reduce the incidence of errors and the learning opportunities from mistakes will be missed. Future errors will therefore not reduce and may actually INCREASE as staff will be more inclined to cover-up their failings for fear of reprisal.

Question 23

How can incivility (rudeness) affect patient safety?

Answer 23

Incivility (rudeness) accounts for 40-60% variance in patient outcomes. This affects those directly involved and staff witnessing the incivility.

Question 24

What are ‘learning organisations’?

Answer 24

‘A place where people continually expand their capacity to create the results they truly desire, where new and extensive patterns of thinking are nurtured, where collective aspiration is set free and where people are continually learning how to learn together’.

Question 25

System vs individual approach to error?

Answer 25

A systems rather than individual approach to error increases reporting rates and is more effective in improving safety.

Question 26

What is cognitive dissonance?

Answer 26

It describes the inner tension we feel when our beliefs are challenged. It is bound together with self-esteem and can be a SUBCONSCIOUS reaction to situations where we have made a mistake or error of judgement.

Is a deeply ingrained human trait. The more we have riding on our judgements, the more likely we are to manipulate any new evidence that calls them into question”.

Question 27

Is cognitive dissonance always conscious?

Answer 27

No - we may not realise it is happening and we may go to great lengths to deny the evidence of our erroneous judgements TO OURSELVES as well as to others.

Question 28

What is confirmation bias?

Answer 28

Seeking evidence to confirm what we already believe.

Ignoring (even subconsciously) evidence that refutes this belief.

Question 29

What is key to moving beyond ‘confirmation bias’?

Answer 29

Learning the skill of critical appraisal: why are you sympathetic to a particular viewpoint?

Question 30

What is the Harvard Implicit Association Test?

Answer 30

The Implicit Association Test (IAT) measures attitudes and beliefs that people may be unwilling or unable to report.

Question 31

What is unconscious bias?

Answer 31

Unconscious Bias refers to bias we are unaware of and which happens outside of our control. You could think of it as an example of System 1 thinking (pattern recognition based on your previous life experiences).

Question 32

How can you work to overcome unconscious bias?

Answer 32

Raise awareness of own implicit biases

Aim to engage with a wide variety of people from different backgrounds

Look after yourself. Bias is more likely to occur when you are tired, hungry or stressed

Look for opportunities to challenge and change systems and processes that are perpetuating biased outcomes.

Question 33

What is a ‘just culture’?

Answer 33

A just culture considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution.

Question 34

When is cognitive dissonance more often experienced?

Answer 34

when there has been a difficult induction into a group or when the stakes for failure are high

Question 35

How do ‘side effects’ differ from ‘adverse events’ in regards to medication?

Answer 35

Side effects: are predictable and can be counselled for by the clinician prescribing the medication.

Adverse events: usually less easily predicted and can be more severe.

Question 36

What should you be sure to ask about when prescribing medications?

Answer 36

• Over-the-counter, herbal, and homeopathic remedies
• Recreational drugs
• Increasingly, it is possible to obtain drugs or therapies that have not passed sufficient regulatory procedures over the internet e.g. slimming pill

Question 37

What is the 2 point test for mental capacity?

Answer 37

1. Does the person have an impairment, or a disturbance in the functioning, of their mind or brain?
2. Does the impairment or disturbance mean that the person is unable to make a specific decision when they need to? You should offer all appropriate and practical support to achieve this before applying this stage of the test.

Question 38

To be able to make a decision a person should be able to do what 4 things?

Answer 38

1. Understand the decision
2. Retain the information
3. Use that information in making the decision – a person should be able to weigh up the pros and cons of making the decision.
4. Communicate their decision

Question 39

What was the ‘Montgomery Ruling’?

Answer 39

The doctor is under a duty totake reasonable careto ensure that the patient is aware of anymaterial risksinvolved in any recommended treatment, and ofany reasonable alternativeor variant treatments.

Question 40

What is a ‘material risk’?

Answer 40

A significant potential for harm that a reasonable person would want to consider when making a decision about undergoing a medical or surgical treatment.

Question 41

What is the ‘duty of candour’?

Answer 41

Every healthcare professional must be open and honest with patients when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress.

In other words, if a significant error has occurred, it is your (or your employer’s) legal duty to inform those affected.

Question 42

What needs to be assessed when consenting patients?

Answer 42

Mental capacity

Question 43

If there there is a risk of a serious or adverse outcome, what must be ensured?

Answer 43

Patients must be made aware as part of their decision making