Patient Safety Flashcards
What is the definition of an adverse event?
an injury resulting in prolonged hospitalisation, disability or death caused be healthcare management
What is the definition of a significant event?
an event thought by anyone in the team to be significant in the care of patients or the conduct or practice or organisation
What is the definition of a near miss?
an error that has the potential to cause an adverse event but fails to do so because of chance or because it is intercepted
What is meant by a serious incident?
unexpected or avoidable death or serious harm
these are “never events”
a scenario that prevents or threatens to prevent an organisation’s ability to continue to deliver healthcare services
What is meant by clinicians having a “Duty of Candour”?
as all clinicians have a professional duty of candour, they must report errors at an early stage
this allows lessons to be learnt quickly and patients are protected from harm in the future
What are the 5 different types of incidents?
clinical incidents:
- related to planning, organisation, delivery of care, treatment or procedures
- e.g. delayed diagnosis, misinterpretation of test, equipment error
patient incidents:
- non-treatment related
- e.g. slip, trip, fall
security incidents:
- e.g. theft of property, violence or aggression
staff incidents:
- slips, trips, verbal / physical abuse, exposure to hazardous substances
information governance incidents
What is meant by the adverse event iceberg?
the majority of incidents remain unreported:
- unnoticed errors
- near misses
- errors considered insignificant
errors that could cause harm and serious errors are reported
What would help encourage people to have the freedom to speak up and report incidents?
- culture of safety
- culture of raising concerns
- culture free from bullying
- structure to facilitate reporting of both formal and informal concerns
- prompt, swift, proportionate, fair and blame-free investigations
What should an increase in incident reporting be interpreted as?
an increase in incident reporting should not be taken as an indication of worsening patient safety
but rather as an increasing level of awareness of patient safety issues and a more open and transparent culture
What is meant by ‘clinical risk management’?
specifically concerned with improving the quality and safety of healthcare services
by identifying the circumstances and opportunities that put patients at risk of harm
and acting to prevent or control those risks
What is the difference between hazards and risks?
hazards:
- things that could cause harm
risks:
- the likelihood that an incident would occur and how bad the consequences would be
What should be done when a hazard is noticed?
when we notice a hazard, we need to think about:
- how serious it is
- how soon it is likely to cause harm
- how urgently we need to take action
this is done by calculating the level of risk
What tool is used to calculate the level of risk?
risk matrix
consequence score of 1 - 5 from no harm to catastrophic
likelihood score of 1 - 5 based on the chance that the incident will happen
How is risk score calculated?
What is it based on?
multiply the consequence score by the likelihood score
this is based on actual harm from the incident and not potential harm
a serious incident is a score > 15
What is the NRLS?
national reporting and learning system
it is the national database for patient safety incidents
it receives over 1.5million reports each year, mainly from secondary care
What is the purpose of the national reporting and learning system (NRLS)?
clinicians and safety experts analyse reports to identify common risks and opportunities to improve patient safety
e.g. national campaigns on handwashing
In general, what is a serious incident?
an incident where a patient, member of staff or member of the public has suffered serious injury, major permanent harm or unexpected death
or
where there is a cluster of incidents or actions by NHS staff which have caused or are likely to cause significant harm or public concern
What are the 3 definitions of a serious incident?
a serious incident results in one of the following:
- unexpected or avoidable death of patients, staff, visitors or public
- serious harm to patients, staff, visitors or public
- a scenario that prevents or threatens to prevent an organisation’s ability to continue to deliver healthcare services
What must happen in order for serious harm to patients, staff visitors or the public to be classed as a serious incident?
- requires life-saving intervention, major surgical / medical intervention
- results in permanent harm or shortens life expectancy or results in prolonged pain or psychological harm
What are examples of scenarios that prevent or threaten to prevent an organisation’s ability to continue to deliver healthcare services?
- actual or potential loss of personal / organisational information
- damage to property, reputation or the environment, or IT failure
- allegations of abuse
- adverse media coverage or public concern about the organisation
What are examples of never events?
- wrong site surgery
- retained foreign object post-procedure
- wrong implant
- overdose of methotrexate in non-cancer patients
- misplaced naso-gastric feeding tube
- chest or neck entrapment in bed rails
- transfusion or transplantation ABO incompatible blood components or organs
- wrong route administration of medication
- maladministration of potassium containing solutions
- overdose of insulin due to abbreviation or incorrect device
- failure to install collapsible shower / curtain rails
- falls from poorly restricted windows
- scalding of patients
- mis-selection of high dose midazolam during sedation
What is involved in the significant incident (SI) process?
- identify and respond
- communicate to patients
- report
- investigate using RCA - process in timely manner
- CCG review and respond
- action plan - develop, agree and implement
- disseminate learning and monitor
What are the 3 stages in root cause analysis?
react:
- what were the critical problems?
record:
- what were the main contributory factors / root causes?
respond:
- what needs to be done?
What tools can be used to help in root cause analysis?
- timeline
- swiss cheese model - active and latent failures
- contributory factors - organisational accident model, fishbone diagram
