Patient Safety & Risk Mgmt (Wk 3)

Question 2

2 types of medical error (error of _____)

Answer 2

Error of execution (failure of planned action to be completed as intended)

Error of planning (use of wrong plan to achieve an aim)

Question 3

Most Common root causes of medical errors

Answer 3

1. Communication problems **
2. Inadequate info flow
3. Human errors
4. Pt-related issues
5. Organisational transfer of knowledge/training
6. Staffing
7. Technical failures
8. Inadequate policies & procedures

Question 4

What do the HOLES in the Swiss Cheese Model represent?

Answer 4

Failures or gaps in the system which can allow errors to pass through

Question 5

What are some “HOLES” in the Swiss Cheese Model (for healthcare)?

Answer 5

Incomplete documentation
Inadequate shift handover
Lack of clear clinical guidelines
No supervision for new staff

Question 6

What are “ACTIVE FAILURES” in the Swiss Cheese Model?

Answer 6

Unsafe acts that can be directly linked to an accident involving frontline staff e.g. fail to do 2 pt identifiers

Question 7

What are LATENT FAILURES in the Swiss Cheese Model?

Answer 7

Contributory factors that may lie dormant for days, wks or months until they contribute to the accident

E.g. no maintenance of equipment

Question 8

When all the ‘holes’ in each cheese are PERFECTLY ALIGNED,…..

Answer 8

Error will pass straight thru each cheese instead of being blocked –> harm reach patient

Question 9

What contributes to HOLES in Cheese?

Answer 9

• Human error
• Medicine is complex and uncertain (variations in healthcare)
• “Defective system” / Blind spots e.g. ampoules look the same, lack of checks
• Healthcare leans on tradition (has not tried to make itself safe)

Question 10

Evolution of Safety Culture

Answer 10

Blame –> No blame –> Just

Question 11

Why do we no longer practice the “NO BLAME culture”?

Answer 11

Staff didn’t assume responsibility for mistakes they make

Question 12

Why is “BLAME CULTURE” no longer practised?

Answer 12

Looking for scapegoats –> A lot of incidents goes uncovered

Question 13

3 types of “JUST CULTURE” behaviour

Answer 13

Human error
At risk behaviour (Unintentional risk-taking)
Reckless behaviour

Question 14

Actions taken for each type of “JUST CULTURE” behaviour

Answer 14

Human error –> Console
At-risk behaviour –> Coach
Reckless behaviour –> PUNISH

Question 15

Why is risk mgmt required?

Answer 15

Only alternative is crisis mgmt which is more ex, time consuming, embarrassing

prepare for the worst

take advantage of opportunities to improve services or lower costs

Question 16

Healthcare Risk Mgmt definition

Answer 16

A comprehensive system or process through which risks to the organization and all who are served and associated with it, are identified, classified, evaluated and controlled to predict, limit and reduce future potentials for risks and losses.

Question 17

Steps of risk mgmt

Answer 17

1. Risk Identification
2. Risk Analysis
3. Risk Mitigation / Control
4. Risk Monitoring / Review

Question 18

2 main components of Risk Identification

Answer 18

1. Root Cause Analysis (RCA)
2. Healthcare Failure Mode and Effects Analysis (HFMEA)

Question 19

What is Root Cause Analysis?

Answer 19

retrospective review of PAST INCIDENCES
establish root causes for problems & solutions
minimise risk of reoccurences of similar incidents

• Retrospective analysis (after near miss/serious error)
• Chronology of events (leading to incident)

focus on SYSTEMS and PROCESSES

Question 20

What is Healthcare Failure Mode & Effects Analysis?

Answer 20

Proactively look at many steps in a process
flowchart the process, predict where risks exist
redesign process to eliminate those risk

Question 21

What is Risk Analysis/Prioritisation

Answer 21

Analyse to determine risk levels
- Events, patterns & freq of events & system defects that contribute to occurence
- Traits of pts susceptible to high risk events developed
- Envt elements contributing to high risks categorised

Question 22

Why pt complaints are impt

Answer 22

Identify areas of improvement
Common: Communication problems

Question 23

(MUST KNOW) Determining Risks Priority

Answer 23

Risk Priority Number (RPN) =
Likelihood of occurrence of harm x (TIMES) Severity of harm

Question 24

Risks considered significant when:
(HINT: RPN)

Answer 24

RPN > or = 9
Severity or occurrence equal or greater than 4, and without any current control
Legal implications
Affecting reputation of institution

Question 25

Risk Mitigation/Control involes:

Answer 25

Formulate intervention strategies (solicit suggestions & observations from variety of sources)

Question 26

Strategies to mitigate risks

Answer 26

1. Risk Avoidance / Removal
   * Remove the risk by doing things differently where it is feasible to do so (e.g. removal of concentrated KCI from all patient areas)
2. Risk Reduction / Control
   * The development and implementation of policies, standards, procedures and physical changes to reduce risks of adverse events (e.g. performing
   “Time-Out”)
3. Risk Transfer
   * Shifting responsibility or burden for loss to another party through legislation, contract, insurance or other means (e.g. third party vendor for housekeeping service)
4. Risk Acceptance
   * Tolerate the risk - perhaps because nothing can be done at a reasonable cost to mitigate it or the likelihood and impact of the risk occurring are at an acceptable level (e.g. employment of foreign healthcare staff)

Question 27

common strategies for risk mitigation

Answer 27

1. Reduce reliance on memory (e.g. visual aids, checklists)
2. Improve Information Access (e.g. use of IT)
3. Error-proof Processes (e.g. forcing function to change human behaviours)
4. Standardize tasks (e.g. protocols, guidelines)
5. Reduce the number of hand-offs (e.g. integrated care, point-of-care testing)

Question 28

Implementation of risk mitigation solutions

Answer 28

1. Develop an Action Plan
2. Develop process and outcome measures, as appropriate
3. Complete baseline measures of key processes as necessary
4. Implement action plan

Helpful Tip:
* Conduct a pilot test in a selected area before facility-wide implementation

Question 29

What is done for Risk Monitoring?

Answer 29

1. Communicate high alert risks to stakeholders
2. Follow up on risk treatment options and analysis of risk against data to assess effectiveness of the actions taken
   * Review of incident (IRS) and complaint cases
   * Review of organisational policies, strategies and processes
   * Through quality indicators
   * Through performance indicators v Conduct Audits to check compliance
3. Yearly Review of Risks Register to Evaluate Impact

Question 30

Risk Mgmt vs QUality Improvement

Answer 30

RM Focus : Decrease probability of incurring an adverse
outcome
QI Focus: Increase probability of achieving a desired
outcome