Patient safety in a complex system

Question 1

Define an adverse event

Answer 1

Incident resulting in harm to a patient, which is not a direct result of their illness or other chance event

Question 2

What are the 2 outcomes of a medical error?

Answer 2

Near miss

Adverse event

Question 3

Define a near miss

Answer 3

An event which arises during care and has the potential to cause harm but fails to develop further thereby avoiding harm

Question 4

Give 3 types of human error and examples of each

Answer 4

Errors of omission - forget to take a particular action (forgetting to check patient ID before a surgery)
Errors of commission - take a wrong course of action (i.e performing a LP in a meningococcal septicaemia patient)
Professional negligence - consultant forgetting basic stuff that an F1 should know how to do

Question 5

Give 3 types of errors and examples of each

Answer 5

Skill-based (i.e memory lapses, slips of action)
Knowledge-based (i.e failure to implement NICE guidelines correctly)
Rule-based (i.e wrong formula applied to adjust dosage of aminoglycoside antibiotic for patient with renal problems)

Question 6

What are 2 approaches to managing error?

Answer 6

Person approach - Sees errors as pdt of wayward mental processes. Promotes “cover up”

System approach - “Swiss cheese model”. Remedial efforts directed at removing error traps and strengthening defences

Question 7

What are some strategies to reduce errors and harm?

Answer 7

Checklists
IT usage
Team training
Risk management programmes

Question 8

What are 5 elements of a safety culture?

Answer 8

Open - Staff feel comfortable discussing patient safety incidents
Just - Staff, patients and carers are treated fairly, with empathy and consideration when they raise a safety issue
Reporting - Staff are not blamed and unpunished when they report incidents
Learning - Organisation is committed to learn safety lessions
Informed - Organisation is able to learn from past experiences