Patient Safety & Risk Mgmt (Wk 3) Flashcards
2 types of medical error (error of _____)
Error of execution (failure of planned action to be completed as intended)
Error of planning (use of wrong plan to achieve an aim)
Most Common root causes of medical errors
- Communication problems **
- Inadequate info flow
- Human errors
- Pt-related issues
- Organisational transfer of knowledge/training
- Staffing
- Technical failures
- Inadequate policies & procedures
What do the HOLES in the Swiss Cheese Model represent?
Failures or gaps in the system which can allow errors to pass through
What are some “HOLES” in the Swiss Cheese Model (for healthcare)?
Incomplete documentation
Inadequate shift handover
Lack of clear clinical guidelines
No supervision for new staff
What are “ACTIVE FAILURES” in the Swiss Cheese Model?
Unsafe acts that can be directly linked to an accident involving frontline staff e.g. fail to do 2 pt identifiers
What are LATENT FAILURES in the Swiss Cheese Model?
Contributory factors that may lie dormant for days, wks or months until they contribute to the accident
E.g. no maintenance of equipment
When all the ‘holes’ in each cheese are PERFECTLY ALIGNED,…..
Error will pass straight thru each cheese instead of being blocked –> harm reach patient
What contributes to HOLES in Cheese?
- 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)
Evolution of Safety Culture
Blame –> No blame –> Just
Why do we no longer practice the “NO BLAME culture”?
Staff didn’t assume responsibility for mistakes they make
Why is “BLAME CULTURE” no longer practised?
Looking for scapegoats –> A lot of incidents goes uncovered
3 types of “JUST CULTURE” behaviour
Human error
At risk behaviour (Unintentional risk-taking)
Reckless behaviour
Actions taken for each type of “JUST CULTURE” behaviour
Human error –> Console
At-risk behaviour –> Coach
Reckless behaviour –> PUNISH
Why is risk mgmt required?
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
Healthcare Risk Mgmt definition
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.
Steps of risk mgmt
- Risk Identification
- Risk Analysis
- Risk Mitigation / Control
- Risk Monitoring / Review
2 main components of Risk Identification
- Root Cause Analysis (RCA)
- Healthcare Failure Mode and Effects Analysis (HFMEA)
What is Root Cause Analysis?
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
What is Healthcare Failure Mode & Effects Analysis?
Proactively look at many steps in a process
flowchart the process, predict where risks exist
redesign process to eliminate those risk
What is Risk Analysis/Prioritisation
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
Why pt complaints are impt
Identify areas of improvement
Common: Communication problems
(MUST KNOW) Determining Risks Priority
Risk Priority Number (RPN) =
Likelihood of occurrence of harm x (TIMES) Severity of harm
Risks considered significant when:
(HINT: RPN)
RPN > or = 9
Severity or occurrence equal or greater than 4, and without any current control
Legal implications
Affecting reputation of institution
Risk Mitigation/Control involes:
Formulate intervention strategies (solicit suggestions & observations from variety of sources)
Strategies to mitigate risks
- 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) - 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”) - 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) - 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)
common strategies for risk mitigation
- Reduce reliance on memory (e.g. visual aids, checklists)
- Improve Information Access (e.g. use of IT)
- Error-proof Processes (e.g. forcing function to change human behaviours)
- Standardize tasks (e.g. protocols, guidelines)
- Reduce the number of hand-offs (e.g. integrated care, point-of-care testing)
Implementation of risk mitigation solutions
- Develop an Action Plan
- Develop process and outcome measures, as appropriate
- Complete baseline measures of key processes as necessary
- Implement action plan
Helpful Tip:
* Conduct a pilot test in a selected area before facility-wide implementation
What is done for Risk Monitoring?
- Communicate high alert risks to stakeholders
- 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 - Yearly Review of Risks Register to Evaluate Impact
Risk Mgmt vs QUality Improvement
RM Focus : Decrease probability of incurring an adverse
outcome
QI Focus: Increase probability of achieving a desired
outcome
