Patient Safety, Medical Error

Question 1

Define never event and examples

Answer 1

a serious, largely preventable patient safety incident which should not occur if the available preventative measures have been implemented.

e.g.
Wrong site surgery/ foreign object retained.
Wrong drug dose/ route.
ABO incompatibility.
Mental health: escape of transfer patient.

(there are 14 never events??)

Question 2

Consequences of never events

Answer 2

Cause harm or even death to patients
Show gaps in the provision of quality care
Are published in National Quality data
Affect the reputation of the Trust with, patients, public and staff
Have financial penalties
Prompt visits by external agencies e.g. CQC, Monitor, Commissioners

Question 3

3 occasions in which you can breach confidentiality

Answer 3

1. If they are a risk to the public (they intend to commit a crime). Ie: benefits to society/ an individual outweigh the benefits of maintaining confidentiality.
2. If they have given consent.
3. If it is required by law: notifiable diseases (eg: ebola), a judge orders you to do so (eg: as part of a GMC investigation).

Question 4

Define Heinrich’s triangle theory/law

Answer 4

Heinrich’s Law: in a workplace, for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injuries. (ie. lots of accidents happen which never result in harm to patients)

Question 5

What is the biggest issue relating to patient safety

Answer 5

Communication (between and within teams)

- responsible for 70% of errors

Question 6

Tools of risk identification re patient safety

Answer 6

• incident reporting
• complaints and claims
• audit, service evaluation and benchmarking
• external accreditation
• active measurement/compliance

Question 7

How is duty of candour (= legal requirement) involved in patient safety

Answer 7

• statutory duty (apologise + put it in writing)
• incident + harm (MOD + greater???)
• honest reporting
• transparency with patients/relatives
• speedy review of incidents
• it is what we expect from ourselves

Question 8

How to learn from never events

Answer 8

• determine root cause
• develop action plan
• do they work
• has risk been generated elsewhere

Question 9

What goes wrong in never events (Mid-staffs)

Answer 9

• culture
• incident reporting
• failure to act on info
• acceptance of deviation
• whistle blowing
• duty of candour

Question 10

Key themes for improvement of patient safety from a hospital perspective

Answer 10

• leadership
• quality as main focus
• patient/public involvment
• staff
• quality/safe training
• transparency
• regulation/enforcement

Question 11

Human factors in patient safety

Answer 11

• teamwork
• leadership
• lack of resources
• distraction
• stress
• fatigue
• lack of assertiveness
• situational judgment
• lack of knowledge
• complacency
• norms
• communication

Question 12

Facts from elaine bromiley case (2005)

Mrs Elaine Bromiley presented for elective surgery for septoplasty and functional endoscopic sinus surgery. There was slight restriction to her neck movement but nothing to suggest a problem with airway management. On arrival in the anaesthetic room routine monitoring was set up, she was not pre-oxygenated. It proved impossible to insert a flexible laryngeal mask and Mrs. Bromiley’s oxygenation level began to deteriorate and she appeared blue. Oxygen saturation deteriorated to a low level of 40% and it proved impossible to ventilate her.
A recognised emergency “can’t intubate, can’t ventilate” arose and there were further failed
attempts at intubation. A tracheostomy set was called for but was not used. Oxygen saturation
levels remained unstable and at 9.10 the proposed surgical procedure was abandoned to allow
Mrs. Bromiley to wake up.
The management of the “can’t intubate can’t ventilate” emergency did not follow the current or
any recognised guidance. Too much time was taken trying to intubate the trachea rather than
concentrating on ensuring adequate oxygenation. The clinicians became oblivious to the passing
of time and thus lost opportunities to limit the extent of damage caused by the prolonged period of hypoxia. Not all the clinicians were aware that there was a problem with ventilating Mrs.
Bromiley.
Surgical airway access by either tracheotomy or cricothyrotomy should have been considered and carried out.
Given the prolonged period of hypoxia Mrs Bromiley should have been admitted to ICU rather than to the recovery room.

Answer 12

• Loss of situational awareness – stress of situations – just repeating same actions
• Perception and cognition – actions not in line with emergency protocol
• Teamwork – no clear leader
• Culture – Nurses brought the emergency kit to the room and alerted the ICU, but did not raise their concerns aloud when they were not utilised. The hierarchy of the team made assertiveness difficult despite the severity of the situation.

Question 13

Red flags: the symptoms and sign of evolving error chains

Answer 13

• Ambiguities/anomalies/ conflicting information/surprises.
• Alarm bells in your mind or warning from equipment
• Broken communication or inconclusive discussions
• Confusion/loss of awareness/uncertainties
• Departures from standard procedures/normal practices
• Fixation/pre occupation
• Missing information/incomplete briefing
• Time distortion/event runaway
• Unease/fear; Denial/ stress/action

Question 14

Explain 3 buckets model

Answer 14

Professor Reason proposed the ‘three buckets model’ to help health care professionals evaluate their error risk. The amount of perceived risk in each ‘bucket’ is rated as (1) low, (2) medium or (3) high.

Self: This bucket concerns the individual health care worker. For example, is he or she fatigued and do they have the necessary experience and knowledge to deal with the demands at that time.
Context: This bucket represents all contextual factors, including environmental factors (distractions, interruptions, handovers), equipment failures, inadequate resources and time.
Task: This bucket contains all factors related to the task at hand and includes the task complexity, duration and physical demands

NB.
Each bucket may contain postiive or negative factors. Buckets are never empty; there is always risk just to varying levels. (estimated) likelihood of error represented by combination of 3 bucket contents.

Question 15

2 examples to reduce human error

Answer 15

1. Surgical safety checklist (patient identity, site marked, anaesthesia complete, allergy, difficult airway, risk of significant blood loss, confirm team members and their roles, dr/anaesthetist/nurses have any concerns?)
2. SBAR (situation, background, assessment, recommendation)

Question 16

Cultural issues re patient safety

Answer 16

• Top-heavy structure (i.e., power/control)
• Lack of clear identity
• No clarity on who was responsible
• Lack of inter professional collaboration

eg. Baby P, bristol heart scandal

Question 17

Define the conformity problem

Answer 17

The greater the benefits and lower the likely consequences, the more common it is for people to ‘migrate’ towards working in ways that they know to be wrong or that break the rules. Over time these ways become normalised and are integrated into the culture

Question 18

3 types of leadership

Answer 18

Transactional: Where the leader causes a follower to act in a certain way in return for something the follower wants to have (or avoid). For example, by offering higher pay in return for increased productivity; or tax cuts in exchange for votes.

Transformational: Where the leader taps into his followers’ higher needs and values, inspires them with new possibilities that have strong appeal and raises their level of confidence, conviction and desire to achieve a common, moral purpose.

Laissez-faire

Question 19

Leadership factors

Answer 19

• Integrity and fairness.
• Sets clear goals.
• Has high expectations and encourages others.
• Provides support and recognition to others.
• Gets people to look beyond their self-interest.
• Creates a connection with others to raise the motivation and morality of the leaders and followers.
• Transformational leadership is concerned with values, ethics, standards, and long-term goals

Question 20

What qualities demonstrate courage

Answer 20

• Can have difficult but respectful conversations
• Prioritise regardless of not being able to please everyone
• Can support others through the process of change, even if they are suffering because of it
• Can listen and adjust strongly held views according to evidence
• Have sufficient confidence to respond to criticism

Question 21

Transformational leadership as a F1

Answer 21

Place the needs of patients, families and carers at the centre of all your work; and intervene when necessary

Be a quality inspector, never knowingly passing on a defect, error or risk to a colleague or patient, putting things right where you can, and reporting everything, especially where you need help to put it right.

Also responsible to help continuously improve healthcare system in collaboration with others.

Be willing to speak up to leaders when you believe that a lack of skills, knowledge or resources places patients at risk of harm, and be willing to listen to others when they identify these risks.

Question 22

Mechanisms underlying inhumane behaviour

Answer 22

• Bystander effect:
• • number of bystanders - leadership
• • Ambiguity of the situation
• • Similarity of bystander to victim
• Pressing situational factors can over ride explicitly enounced value systems – e.g.,
  Worcestershire trust- the patients who died in their trollies waiting to be seen (this winter)
• Conformity (Asch) – Unwillingness to speak against prevailing view
• Ill chosen targets! – 4 hour waiting time; weight control changes in dietary behaviour vs weight loss

Question 23

Sloth error

–> how to avoid error

Answer 23

Not bothering to check results/information for accuracy.
Incomplete evaluation.
Inadequate documentation.

--> conscientious:
Attention to detail.
Completeness. 
Not assuming that information presented to you is correct. 
Full documentation.

Question 24

Fixation and loss of perspective error

Answer 24

Early unshakeable focus on a diagnosis.
Inability to see bigger picture.
Overlooking warning signs.

–> open mindedness, situational awareness:
Recognition of the clinical patterns but considering
facts that don’t fit.
Reevaluation if deviation from the expected.

Question 25

Communication breakdown error

Answer 25

Unclear instructions or plans.
Not listening to or considering others opinions.

–> effective communication:
Being approachable and open.
Listening.
Clear explanation with appropriate terminology and reinforcement.

Question 26

Poor team working error

Answer 26

Team members working independently.
Poor direction.
Some individuals out of depth, others underutilised.

–> good team working:
Clear team structure and roles with sharing of views, concerns and management plans.
Clear logical leadership

Question 27

Playing the odds error

Answer 27

Choosing the common and dismissing the rare event.

–> probability assessment:
Evaluation based on scenario features as well as likelihood

Question 28

Bravado (timidity) error

Answer 28

Working beyond your competence or without adequate supervision.
A show of confidence to hide underlying deficiencies (not taking on that which you should)

–> humility:
accurate self evaluation.
open communication to mistakes.

Question 29

Ignorance error

Answer 29

Lack of knowledge.
Unconscious incompetence.
Not knowing what you don’t know.

–> self-awareness :
Aware of your own abilities and limitations.
Consideration of factors which may affect your judgement (e.g., stress, fatigue)

Question 30

Mis-triage error

Answer 30

Over/under-estimating the seriousness of a situation.

–> prioritisation:
Appreciation of the relative importance or urgency of each situation.

Question 31

Lack of skill error

Answer 31

Lack of approrpriate skills, teaching or practice.

–> effective technical skills:
being properly trained in your role

Question 32

System error

Answer 32

Environmental, technology, equipment or organisational
features.
Inadequate built in safeguards.

–> system design:
A system designed to be easy to use, complete, and with design features that identify potential risk.