PPD Flashcards
What is an error?
An unintended outcome
List some common issues regarding safety in healthcare:
- Wrong diagnosis -> wrong plan
- Medication reconciliation
- Patient identification
- Patient care handovers
- Medication identification
List the types of error which can occur:
- Intention (failure of planned actions to achieve outcome)
- Action (e.g. wrong blood vessel)
- Outcome (e.g. near miss, death)
- Context (e.g. team factors, accumulation of stressors)
List the 2 perspectives of error:
Person approach (individuals fault): - shortcoming= blame culture
System approach (working conditions):
- errors are common place so adverse events are the product of many causal factors
- error lies in the system rather than individual
List some strategies used to reduce errors and harm:
- Simplification and standardisation of clinical processes
- Checklists - SBAR
- Team training
List some tools used to identify risks:
- Incident reporting
- Complaints and claims
- Audits
- External accreditation
What is a never event?
A serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented (e.g. surgery on wrong site, wrong preparation of medicine, mental health= suicide).
List 4 leadership styles:
- Inspirational
- Transactional (communicating)
- Laissez-faire
- Transformational (leadership throughout all levels of organisation)
List 3 mechanisms which can underlie inhumane behaviour:
- Bystander effect
- Situational factors (over-ride value systems)
- Unwillingness to speak out
List 5 types of basic error:
(all these forms of error have a reciprocal skill, behaviour or attribute which is more desirable):
- Sloth (not bothered)
- Loss of perspective
- Communication breakdown
- Poor team working
- Bravado (working beyond competence)
- Ignorance (lack of knowledge)
List 5 reasons why ‘things go wrong’:
- System failure
- Human factors
- Judgement failure
- Neglect
- Poor performance
What 4 questions can be asked to ascertain whether negligence has occurred?
1) Is there a duty of care?
2) Was there a breach of that duty? (would a group of reasonable doctors do the same? - Bolam test)
3) Did the patient come to any harm?
4) Did the breach cause that harm?
What is the Swiss cheese model?
In the Swiss Cheese model, an organization’s defenses against failure are modeled as a series of barriers, represented as slices of cheese. The holes in the slices represent weaknesses in individual parts of the system and are continually varying in size and position across the slices. The system 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 a failure
What are the 4 types of learner?
- Theorist (questions ideas)
- Activist (Extroverted)
- Pragmatist (wants feedback)
- Reflector (watches others)
What is Kolbs learning cycle?
1) Experience (activist)
2) Review, reflect of experience (reflector)
3) Conclusions from experience (theorist)
4) What can I do next time? (pragmatist)
