Patient Safety And Human Factors Flashcards
In terms of healthcare quality, what does safe mean?
No needless deaths
In terms of healthcare quality, what does effective mean?
No needless pain or suffering
In terms of healthcare quality, what does patient-centred mean?
Focus on patient’s needs and priorities
In terms of healthcare quality, what does timely mean?
No unwanted waiting
In terms of healthcare quality, what does efficient mean?
No waste
In terms of healthcare quality, what does equitable mean?
No one left out
What is meant by adverse event?
An injury that is caused by medical management and that prolongs the hospitalisation, produces disability or both
What is meant by the term preventable adverse event?
An adverse event that could be prevented given the current state of medical knowledge
How can human error be avoided?
Avoid reliance on memory Make things visible Review and simplify processes Standardise common processes and procedures Routinely use checklists
What is first order problem solving?
Doing 2 things when encountering a problem:
- Do what it take to continue pt care task, no more no less.
- meets immediate need and minimises time away from pt care - Ask for help from people who are socially close rather than those who are best equipped to correct the problem
- preserves reputation, minimises difficult encounters
This is essentially doing the least you can
What is secondary order problem solving?
When something is done to prevent things from reoccurring by reflection
Reduces likelihood of errors recurring and errors causing harm
Why might people not want to second order problem solve?
Don’t want to change their ways
What are the two types of failure as stated by the James reason’s framework of error
Active and latent
What is an active failure?
Acts that lead directly to the pt being harmed
Eg slips and lapses, mistakes, violations etc
What is a latent failure?
Predisposing conditions that means active failures are more likely to occur
Eg poor training, poor design of syringe, too few staff etc
