PH Errors Flashcards
Sloth
E.g. not bothering to check results/info for accuracy, inadequate documenting
Fixation and loss of perspective
E.g. Early unshakeable focus on a diagnosis. Inability to see bigger picture
Communication breakdown
Unclear instructions or plans, not listening to others or considering others opinions
Poor team working
Team members working independently. Poor direction. Some individuals out of depth, others underutilised.
Playing the odds
Choosing the common and dismissing the rare events
Bravado / timidity
Working beyond your competence or without adequate supervision
A show of confidence to hide underlying deficiencies
Ignorance
Lack of knowledge
Unconscious incompetence
Not knowing what you don’t know
Mis-triage
Over/underestimating the seriousness of a situation
Lack of skill
Lack of appropriate skills, teaching or practices
System error
Environmental, technological, equipment or organisational features
Inadequate built in safeguards
conscientiousness
Attention to detail
Completeness
not assuming all information presented is correct
Full documentation
Opposite of sloth
Open mindfulness/situational awareness
Recognition of clinical patterns but considering facts that don’t fit
Re-evaluation if a deviation from expected
Opposite of fixation/loss of perspective
Effective communication
bring approachable and open
Listening
Clear explanation and appropriate terminology and reinforcement
Opposite of communication breakdown
Good team working
Clear team structures and roles with sharing of views, concerns, management plans
Clear logical leadership
Opposite of poor team working
Probability assessment
Evaluation based on scenario and features as well as the likelihood
Opposite of playing the odds
Humility
Accurate self-evaluation
Open communication of mistakes
Opposite of bravado
Self-awareness
Aware of own abilities and limitations
Consideration of factors which may affect judgement (e.g. stress/fatigue
Opposite of ignorance
Prioritisation
Appreciation of relative importance or urgency of problems
Opposite of mis-triage
Effective technical skills
Being properly trained in your role
Opposite of lack of skill
System design
A system designed to be easy to use, complete and with design features that identify potential risk
Opposite of system error
