Patient safety in a complex system Flashcards
what are some of the reasons why pt safety is compromised so often?
- healthcare is a complex, high risk environment
- the healthcare system is resource intensive
- there are a lot if interactions between the system, pt, family and the practitioner - so there is shared responsibility, which can lead to people being uncertain whether they are responsible or not
- practitioners may take risks unknowingly eg by doing operations at the border of their expertise
what is the system approach to patient safety?
- errors are to be expected and are part of human nature
- removes the blame culture and appreciates that adverse events are the product of many causal factors
- remedial effects look at strengthening defences rather than punishing individuals
what are active failures?
errors by people at the sharp end, that are open, short lived gaps in the defensive layers
what are latent conditions?
these are a consequence of high level management decisions - the structure of the system and how it is built
the effects of latent conditions can be quite long lasting
these latent conditions may lie dormant within the system for many years
they can be identified and remedied before an adverse event occurs
how do active failures and latent conditions interact?
latent conditions can lie dormant for many years before they combine with active failures to create an accident
what is the individual approach to pt safety?
- Views errors as result of problematic mental processes - forgetfulness, inattention, distraction, carelessness, poor
motivation, negligence, recklessness - Focuses on unsafe acts of people at the sharp end
- Anticipation of blame promotes “cover up” of the problem and who was involved
define culture
shard VALUES and BELIEFS that interact with an organisation’s structure and control systems to produced BEHAVIOURAL NORMS
what is a positive safety culture?
- staff have a constant and active awareness of the POTENTIAL for things to go wrong
- open and fair and encourages people to SPEAK UP about mistakes
- SHARED values and responsibilities
- everyone takes responsibility for pt safety and ACTS when necessary
what is a open culture?
staff feel COMFORTABLE discussing pt safety incidents and raising safety issues with both colleagues and senior managers
what is a just culture?
staff, pts and carers are treated FAIRLY with EMPATHY and consideration when they have been involved in a pt safety incident or have raised a safety issue
what is a reporting culture?
where staff have CONFIDENCE in the local incident reporting system and USE it to notify healthcare managers of incidents and near misses
BARRIERS to reporting have been REMOVED and staff are NOT blamed or punished when they report incidents
reporting process is EASY
staff receive CONSTRUCTIVE FEEDBACK after submitting an incident report
trust here is really important
what is a learning culture?
the organisation is committed to LEARNING safety LESSONS and COMMUNICATES these to colleagues and REMEMBERS them over time
what is an informed culture?
the organisation has LEARNT from past experiences and has the ability to identify and mitigate FUTURE incidents
what are the key elements of a positive safety culture?
open culture just reporting culture learning culture informed culture
what is the biggest hurdle to a positive safety culture?
lack of reporting
