Patient Safety

Question 1

What are the weaknesses of FMEA?

Answer 1

Different teams won’t always have the same analysis

Very time consuming

Little guidance on interventions

Question 2

Name 5 different Proactive Risk Managment Techniques

Answer 2

Data Collection

Task Description

Task Simulation –> Eg, SIM Man

Human Error Identification and Analysis –> FMEA

Human Error Quantification –> Probability of an error

Question 3

What are the 6 stages in ‘Faliure Modes and Effects Analysis’ (FEMA)?

Answer 3

1 –> Graphically describe the process

2 –> Identify faliure modes

3 –> Assign each faliure modes to the causation model (eg, lapses/slips/violations/mistakes)

4 –> Design Interventions for faliure modes (eg, what to do to prevent slips/lapses etc)

5 –> Identify outcome measures for interventions (eg, near miss sheet)

6 –> Implement and monitor interventions

Question 4

What type of ‘Unsafe Acts’ can occur?

Answer 4

Unintended Action –> Slip/lapse/mistake

Intended Action –> Mistake/violation

Question 5

What is FMEA?

Answer 5

Faliure Modes and Effects Analysis

A systemic method, carried out by teams, to identify and prevent process errors and product problems before they occur

Question 6

What is Root Causes Analysis?

And what are the 6 stages?

Answer 6

A structured investigation that aims to identify the true cause of a problem and the actions necessary to eliminate them

1 –> Gathering information about the incident

2 –> Mapping the information

3 –> Identifying problems

4 –> Analysing contributary factors (eg, why? questions)

5 –> Determining the root causes

6 –> Developing recommendations and implementing solutions

Question 7

What’s the difference between Proactive and Reactive risk management?

Answer 7

Proactive –> Before the mistake has occured (eg, FMEA)

Reactive –> After the mistake has occured (eg, root cause analysis)

Question 8

Describe Reasons’ Swiss Cheese Model

Answer 8

Every organisation will have a set of ‘barriers’ to prevent mistakes, however if a specific set of things all happen at once then mistakes (organisational losses) can still happen (eg, fit through the holes in the cheese)

Resident Pathogens (latent conditions) –> Decisions made my management that can cause mistakes more common

Unsafe Acts/Faliures –> Things done by people carrying out the task

Question 9

What are the 2 types of ‘Resident Pathogens’ within a system?

And what are the 5 different factors?

Answer 9

Error provoking conditions

Long lasting weaknesses

Work Environment –> Eg, high workload/stress

Team –> Eg, poor communication

Individual/Staff –> Eg, lack of knowledge

Task –> Eg, test results not being avaliable

Patients –> Eg, a distressed patient/language problems