Patient Safety and Error

Question 1

What 3 types of human error are there?

Answer 1

1) Omission
2) Commission
3) Negligence

Question 2

Describe each of the 3 errors:

Answer 2

O: When required action delayed/not taken
C: When wrong action taken
N: When action/omission don’t meet standard of ordinary, skilled person

Question 3

What are the 2 outcomes of medical error?

Answer 3

1) Adverse event

2) Near miss

Question 4

Describe an adverse event

Answer 4

Incident that results in harm to a patient

Question 5

Describe a near miss

Answer 5

Event with potential to cause harm, but won’t develop any further so avoids harm

Question 6

What are skill-based errors?

Answer 6

Performing routine task, with little attention causes slip of action/memory lapse

Question 7

What are rule/knowledge based errors?

Answer 7

Incorrect plan/course of action taken either due to emergency/lack of experience
(Usually when more complex task)

Question 8

What are the 5 factors that affect performance?

Answer 8

1) Alcohol
2) Drugs
3) Stress
4) Fatigue
5) Distraction

Question 9

What are the 2 main approaches to manage errors?

Answer 9

1) Person: Errors = product of wayward mental processes (Unsafe acts of people on front-line)
2) System: Adverse events that are product of many causal factors

Question 10

What is the swiss cheese theory of errors?

Answer 10

Interaction between active failures and latent conditions causes accidents. (Successive layers of defences and safeguards but still get through holes)

Question 11

What are the 5 information processing limitations?

Answer 11

1) Automaticity
2) Cognitive Bias
3) Cognitive Interference
4) Selective Attention
5) Transferring expectations