Patient Safety-Hospital Systems

Question 1

What is a healthcare system?

Answer 1

• A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health.
• Includes private providers, patients, education, social care.
Seen from a healthcare professional’s perspective, systems are essential to bring the patient to the professional, and essential to deliver care

Question 2

What makes a good one?

Answer 2

• Makes good care easy, and prevents human fallibility harming the patient.
• Designed for realistic needs-surges and troughs in care
Responsive to changes-needs to serve patients not other way around

Question 3

what are the types of systems?

Answer 3

Physical Structures  
• Human resources
• Processes/Protocols
• Information distribution and storage
• Data analysis 
• Resources allocation

Question 4

Types of physical structures?

Answer 4

Buildings
Devices    
Diagnosis
Monitoring
Treatment

Question 5

What are near misses?

Answer 5

errors not resulting in adverse events

Question 6

what are preventable adverse events?

Answer 6

errors resulting in adverse events

Question 7

non-preventable adverse events

Answer 7

errors in systems

Question 8

personal vs systemic errors?

Answer 8

P-identifies faults, allows blame and retraining, mirrors legal process
S-acknowledges human fallibility, identifies promoting factors, builds safety

Question 9

what is a slip?

Answer 9

good plan, poor execution

skill problem

Question 10

what is a mistake?

Answer 10

bad plan, executed well

knowledge problem

Question 11

violations

Answer 11

deliberate deviation from accepted

attitude problem

Question 12

what must systems do?

Answer 12

• must recognise that they serve and work with people.
  
  • must be designed to manage typical surges of activity

• Human Factors considers both the physical and mental characteristics of people as well as the organisational factor and wider system.

The design and evaluation of tasks, jobs, equipment, environments and systems to make them more compatible with the needs, capabilities and limitations of people.

Question 13

increased risk of error with…?

Answer 13

• unfamiliarity with the task
• inexperience
• shortage of time
• shortage of people
• excess of tasks
• inadequate checking
• poor procedures
• poor human equipment interface
• Tired, hungry professionals

Question 14

How to approach systems?

Answer 14

• Workers are responsible for safety.
• Safety > Financial / Operational goals.
• Encourages identification, communication, and resolution of safety issues.
• Learns from mistakes and accidents.
Funding for effective safety systems

Question 15

How does a system fail?

Answer 15

• Shutdown-crashes and doesn’t work e.g. Electricity
Poor design-human factors, unfit for reality of purpose, under-detailed, unrealistic assumptions of staff, time, workload etc

Question 16

Datix?

Answer 16

• Realisation
	• Reporting
	• Anonymising
	• Duty of Candour to pt
	• Investigation
	• Change
	• Maintenance
Review

Question 17

Serious incident?

Answer 17

• Summary
	• Being open
	• Timeline
	• Narrative
	• Discussion
	• Root cause analysis-why it happened
	• Action plan + responsible officers
• Action Plan
Reviewed and steps