PPD Flashcards
Define Error
an unintended outcome
Discuss the reasons that safety is compromised in an healthcare environment
- Complex, high risk environment
- Resource intensive
- Interaction of systems, practitioners and patient
- Responsibilities are often shared
- Practitioners take risks unknowingly
Common issues that arise compromising safety
- Wrong Dx leading to wrong plan
- Medication reconciliation
- High concentration of medications
- Patient identification
- Patient care handovers
List the types of error
INTENTION
1. Skill-based error: action made is not what was intended
- Rule-based error: incorrect application of a rule/inadequacy of a plan
- Knowledge-based mistakes:
- Limited attentional resources
- Memory containing min-theories rather than facts
ACTION
- Generic factors: omission, intrusion, wrong order
- Task specific factors: wrong blood vessel, nerve, organ, side
OUTCOME
- Near miss
- Successful detection and recovery
- Death/injury/loss of function
- Prolonged stay in ICU
- Cost of litigation
CONTEXT
- Anticipations and preservations
- Interruptions and distractions
- Nature of the procedure
- Team factors
- Organisational factors
Perspectives on error
Human error:
- Focus on the individual
- Products of wayward processes
- Unsafe acts of people on the front line
- Short comings ( cover up)
System error:
- Errors are the product of many casual factors
- Remedial efforts directed at removing error taps
- Interaction between active failures and latent conditions
Strategies to reduce harm and errors
Simplification and standardisation of clinical process
Checklist and aide memoires ( SBAR)
Information technology
Team training
Risk management programmes
Mechanism to improve uptake of evidence based rx
List the tools of risk identification
Incident reporting Complaints and claims Audit, service evaluation and benchmarking External accreditation Active measurement/compliance
Define a never event
Serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented
Surgery: wrong site/implant, retained item
Medication: wrong prep/route
Mental health: suicide
Types of leadership styles
Inspirational
Transactional
Laissez-faire
Transformational (inclusive leadership is distributed through all levels of an organisation)
Define Negligence
Failure to meet the standards of care expected
Criteria for negligence
- Is there a duty of care?
- Was there a breach in that duty ?
- Are you actions supported by others
- Would group of reasonable doctors do the same
- Would it be reasonable for them to do so? - Did the patient come to any harm?
- Did the breach cause the harm?
- Patients must demonstrate that it was your action/inaction that lead to the harm
List the areas in which negligence could occur
Systems failure
Human factors
- Personal factors
- Teamwork problems
- Working environment
- Decision density
Judgement failure: definitive decision making
- Analytical or intuitive
- Wrong amount/ wrong time of information
- Wrong decision making strategy
- Bias
Neglect
- Not showing sufficient care
- Falling below expected standard
- Chain of minor failures
- Communication failure leading to assumptions
Poor performance
- Repeated minor mistakes
- Not learning from mistakes
- Usually extends beyond attitude
Misconduct
- Deliberate harm
- Covering up errors
- Fraud/theft/abuse- falsely claiming sickness or expenses
- Improper relationship
Explain the Swiss cheese model of error
An organisations defences against failure are modelled as a series of barriers, represented as slices of cheese. The holes in the slices represent weakness in individual parts of the system and are continually varying in some and position across slices.
The systems produces failures when a hole in each slice momentarily aligns, permitting “ a trajectory of accident opportunity” so that a hazard passes through holes in all of the slices, leading to failure.
Approaches to learning
Tripartite model
- Surface: Fear of failure, desire to complete a course. Learning by rote and focus on particular task
- Strategic: Desire to be successful, lead to patchy and variable understanding ( well organised form of surface learning)
- Deep approach: ( Intrinsic, vocational interest, personal understanding): making links across materials, search for deeper understanding of material, look for general principle
Define Kolb’s learning cycle
- Experience (ACTIVIST)
- Review, reflect on the experience (REFLECTOR)
- Conclusions from experience (THEORIST)
- Adapt behaviour, what can be done next time (PRAGMATIST)
Types of learner
Theorist: complex situations, can question ideas, offered challenge
Activist: New experiences, extrovert, likes deep end, leads
Pragmatist: wants feedback, purple, wants copy
Reflector: watches others, reviews work, analyses, collects data
List the responsibilities of small group tutors
Managing the group, the activities and the learning
Facilitator of learning, leading discussions, asking open-ended questions, guiding process and task, enabling active participation of learners
Strategies for structured learning
Evidence Clarification Explanation Linking and extending Hypothetical Cause and effect Summary/synthesis
