Patient Safety Flashcards
What are human factors?
‘All the things that influence human beings affecting how well [they] do any task’
What are human factors that can increase risk to patient safety?
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)
What is ‘cognitive load’?
“Cognitive load” relates to the amount of information that working memory can hold at one time.
What is the ‘swiss cheese model’?
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.
What is the ‘three bucket model’?
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.
Examples of ‘self’ bucket?
- Level of knowledge
- Level of skill
- Current capacity to do task (e.g. tired, ill)
Example of ‘context’ bucket?
- Equipment
- Physical environment
- Workspace
- Team and support
- Organisation and management
Example of ‘task’ bucket?
- Errors
- Task complexity
- Process
What is open loop thinking?
Leads to progress because feedback from failure is rationally acted upon:
- Failures are recognised and acknowledged
What is closed loop thinking?
Failure doesn’t lead to progress because information on errors and weaknesses is misinterpreted or ignored
What is system 1 thinking?
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’.
What is system 2 thinking?
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.
When would you typically use system 1 and 2 thinking?
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.
What is a SEA?
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.
What is a SUI?
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.
What is a ‘never event’?
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
What is the ‘yellow card scheme’?
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.