Patient Safety Flashcards
Define patient safety
Patient safety is the avoidance of unintended or unexpected harm to people during the provision of health care
Patients should be treated in a safe environment and protected from avoidable harm e.g. slip ups, wet surfaces, cables, check wheelchairs, check equipment
State the reporting mechanism for incidents and care that all allied health professions use
Patient safety is supported from the first appointment patients have till the day of discharge by the ‘INTEGRATED CARE SYSTEM’ to ensure the provision of safe care and to help to tackle problems that pass across care settings.
E.g if a patient has Ebola, all allied health professions would be alerted so they are aware.
National patient safety committee established in 2021 role
Look at normal human behaviour and hospital systems to see where do events of harm come from
Since almost 1000 lives die due to lack of patient safety
NHS patient safety strategy and no blame culture
-looks at human error
-NHS looks at how the interplay of normal human behaviour and systems determines patient safety
- There is a mistaken belief that persists that patient safety is about individual effort it’s NOT its everybody’s responsibility
-NHS has no blame culture: we don’t do blaming, we acknowledge the situation happened, we name name staff in the situation and no one takes the blame for it
Reporting system- DATIX
-reporting system for health care professionals
- Report any incidents
-share safety insight
-mechanism to improve safety
-report near misses (almost done)
-enables training for preventions to be put in place
NHS safety vision
-improves patient safety
-change attitude of staff to ensure patient safety is prioritised
-change perception of blame and instead share responsibility
2 foundations and 3 strategies of NHS safety vision
2 foundations
-a patient safety culture
-a patient safety system
3 strategies
-improving understanding of patient safety by drawing intelligence from multiple sources of information
-equipping patients, staff with the skills and opportunities to improve patient safety (involvement)
-designing and support programmes that deliver effective and sustainable change (reporting near misses for self improvement to the DATIX system)
Patient safety incident response system integrates 4 aims
- Compassionate engagement and involvement of those affected by patient safety incidents - may need to produce statements if involved keep it factual
- Application of the same report system to learn from patient safety incidents - we all use the same reporting system to learn from it
3.considered and proportionate responses (strategies) to patient safety incidents - reformation strategy to make quick measured outcomes for improving patient safety
- Supportive oversight focussed in strengthening response system functioning and improvement - learning from situations that occurred and putting preventative measures in place to ensure it doesn’t occur again
Checklists
- checklists are now used for safety standards for invasive procedures
- checklists for theatres , surgeries to ensure everyone understands their role in the team
-to ensure all equipment is present before procedures
-pre list briefing checklists
-checklist champion: co ordinated checklist development implementation and use
-empowers all staff to challenge areas of concern before during after procedures
-audit the use of checklist in all areas (make sure its says what its doing)
-all staff must be introduced to each other and know their role
PAUSED CHCEKLIST FOR RADIOGRAPHY
- PATIENT
- ANATOMY
- USE THE CHECKLISTS
- SYSTEMS AND SETTINGS CHECKS
- EXPOSURE FACTORS
- DO YOU KNOW WHAT TO DO AFTER YOU PRESS THAT BUTTON
NEVER EVENTS
-seriously large preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations
- events that should NEVER occur in practice
E.g. high dose, metal objects in MRI, accidentally irradiate pregnant ladies, don’t expose anatomy that isn’t required
Technology and Safety
- errors in electronic health care systems
- systems unavailable for use or limited functionality
- software hacks/bugs
- human factors
-drop down menu/pick lists
Pop ups with error
If an error pop up appears
-MAKE SURE TO READ IT BEFORE PRESSING OK
Radiography errors
- patient positioning
- Inappropriate use of collimation and grids
- processing errors- cropping images and post processing images
- image artefacts
-under or over exposure
-quality assurance should be completed regularly and any concerns should be reported immediately
-YOU are responsible
Professional responsibility
- you are responsible of your knowledge, skills, behaviour,actions
- if you are unsure ALWAYS SPEAK UP
- skills diminish - use it or lose it keep practicing
-confirm every room you work in has passed Quality care that month
-Verbalise information
-double check everything
-communication is key
