PPD - Patient Safety, medical error Flashcards
Define never event and examples
a serious, largely preventable patient safety incidents which should not occur if the available preventative measures have been implemented.
e.g.
Wrong site surgery/ foreign object retained.
Wrong drug dose/ route.
ABO incompatibility.
Mental health: escape of transfer patient.
(there are 14 never events??)
Consequences of never events
Cause harm or even death to patients
Show gaps in the provision of quality care
Are published in National Quality data
Affect the reputation of the Trust with, patients, public and staff
Have financial penalties
Prompt visits by external agencies e.g. CQC, Monitor, Commissioners
3 occasions in which you can breach confidentiality
- If they are a risk to the public (they intend to commit a crime). Ie: benefits to society/ an individual outweigh the benefits of maintaining confidentiality.
- If they have given consent.
- If it is required by law: notifiable diseases (eg: ebola), a judge orders you to do so (eg: as part of a GMC investigation).
Define Heinrich’s triangle theory/law
Heinrich’s Law: in a workplace, for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injuries. (ie. lots of accidents happen which never result in harm to patients)
What is the biggest issue relating to patient safety
Communication (between and within teams)
- responsible for 70% of errors
Tools of risk identification re patient safety
- incident reporting
- complaints and claims
- audit, service evaluation and benchmarking
- external accreditation
- active measurement/compliance
How is duty of candour (= legal requirement) involved in patient safety
- statutory duty (apologise + put it in writing)
- incident + harm (MOD + greater???)
- honest reporting
- transparency with patients/relatives
- speedy review of incidents
- it is what we expect from ourselves
How to learn from never events
- determine root cause
- develop action plan
- do they work
- has risk been generated elsewhere
What goes wrong in never events (Mid-staffs)
- culture
- incident reporting
- failure to act on info
- acceptance of deviation
- whistle blowing
- duty of candour
Key themes for improvement of patient safety from a hospital perspective
- leadership
- quality as main focus
- patient/public involvment
- staff
- quality/safe training
- transparency
- regulation/enforcement
Human factors in patient safety
- teamwork
- leadership
- lack of resources
- distraction
- stress
- fatigue
- lack of assertiveness
- situational judgment
- lack of knowledge
- complacency
- norms
- communication
Factors from elaine bromiley case (2005)
Mrs Elaine Bromiley presented for elective surgery for septoplasty and functional endoscopic sinus surgery. There was slight restriction to her neck movement but nothing to suggest a problem with airway management. On arrival in the anaesthetic room routine monitoring was set up, she was not pre-oxygenated. It proved impossible to insert a flexible laryngeal mask and Mrs. Bromiley’s oxygenation level began to deteriorate and she appeared blue. Oxygen saturation deteriorated to a low level of 40% and it proved impossible to ventilate her.
A recognised emergency “can’t intubate, can’t ventilate” arose and there were further failed
attempts at intubation. A tracheostomy set was called for but was not used. Oxygen saturation
levels remained unstable and at 9.10 the proposed surgical procedure was abandoned to allow
Mrs. Bromiley to wake up.
The management of the “can’t intubate can’t ventilate” emergency did not follow the current or
any recognised guidance. Too much time was taken trying to intubate the trachea rather than
concentrating on ensuring adequate oxygenation. The clinicians became oblivious to the passing
of time and thus lost opportunities to limit the extent of damage caused by the prolonged period of hypoxia. Not all the clinicians were aware that there was a problem with ventilating Mrs.
Bromiley.
Surgical airway access by either tracheotomy or cricothyrotomy should have been considered and carried out.
Given the prolonged period of hypoxia Mrs Bromiley should have been admitted to ICU rather than to the recovery room.
- Loss of situational awareness – stress of situations – just repeating same actions
- Perception and cognition – actions not in line with emergency protocol
- Teamwork – no clear leader
- Culture – Nurses brought the emergency kit to the room & alerted the ICU, but did not raise
their concerns aloud when they were not utilised. The hierarchy of the team made
assertiveness difficult despite the severity of the situation.
Red flags: the symptoms and sign of evolving error chains
- Ambiguities/anomalies/ conflicting information/surprises.
- Broken communication or inconclusive discussions
- Confusion/loss of awareness/uncertainties
- Missing information/incomplete briefing
- Departures from standard procedures/normal practices
- Fixation/pre occupation
- Time distortion/event runaway
- Unease/fear; Denial/ stress/action
- Alarm bells in your mind or warning from equipment
Explain 3 buckets model
Professor Reason proposed the ‘three buckets model’ to help health care professionals evaluate their error risk. The amount of perceived risk in each ‘bucket’ is rated as (1) low, (2) medium or (3) high.
Self: This bucket concerns the individual health care worker. For example, is he or she fatigued and do they have the necessary experience and knowledge to deal with the demands at that time.
Context: This bucket represents all contextual factors, including environmental factors (distractions, interruptions, handovers), equipment failures, inadequate resources and time.
Task: This bucket contains all factors related to the task at hand and includes the task complexity, duration and physical demands
NB.
Each bucket may contain postiive or negative factors. Buckets are never empty; there is always risk just to varying levels. (estimated) likelihood of error represented by combination of 3 bucket contents.
2 examples to reduce human error
- Surgical safety checklist (patient identity, site marked, anaesthesia complete, allergy, difficult airway, risk of significant blood loss, confirm team members and their roles, dr/anaesthetist/nurses have any concerns?)
- SBAR (situation, background, assessment, recommendation)
Cultural issues re patient safety
- Top-heavy structure (i.e., power/control)
- Lack of clear identity
- No clarity on who was responsible
- Lack of inter professional collaboration
eg. Baby P, bristol heart scandal
define the conformity problem
The greater the benefits and lower the likely consequences, the more common it is for
people to ‘migrate’ towards working in ways that they know to be wrong or that break the
rules. Over time these ways become normalised and are integrated into the culture
3 types of leadership
Transactional: Where the leader causes a follower to act in a certain way in return for something the follower wants to have (or avoid). For example, by offering higher pay in return for increased productivity; or tax cuts in exchange for votes.
Transformational: Where the leader taps into his followers’ higher needs and values, inspires them with new possibilities that have strong appeal and raises their level of confidence, conviction and desire to achieve a common, moral purpose.
Laissez-faire
Leadership factors
- Integrity and fairness.
- Sets clear goals.
- Has high expectations and encourages others.
- Provides support and recognition to others.
- Gets people to look beyond their self-interest.
- Creates a connection with others to raise the motivation and morality of the leaders and
followers. - Transformational leadership is concerned with values, ethics, standards, and long-term
goals
What qualities demonstrate courage
- Can have difficult but respectful conversations
- Prioritise regardless of not being able to please everyone
- Can support others through the process of change, even if they are suffering because of it
- Can listen and adjust strongly held views according to evidence
- Have sufficient confidence to respond to criticism
Transformational leadership as a F1
Place the needs of patients, families and carers at the centre of all your work; and intervene when necessary
Be a quality inspector, never knowingly passing on a defect, error or risk to a colleague or patient, putting things right where you can, and reporting everything, especially where you need help to put it right.
Also responsible to help continuously improve healthcare system in collaboration with others.
Be willing to speak up to leaders when you believe that a lack of skills, knowledge or resources places patients at risk of harm, and be willing to listen to others when they identify these risks.
Mechanisms underlying inhumane behaviour
- Bystander effect:
- number of bystanders - leadership
- Ambiguity of the situation
- Similarity of bystander to victim
- Pressing situational factors can over ride explicitly enounced value systems – e.g.,
Worcestershire trust- the patients who died in their trollies waiting to be seen (this winter) - Conformity (Asch) – Unwillingness to speak against prevailing view
- Ill chosen targets! – 4 hour waiting time; weight control changes in dietary behaviour vs
weight loss
Sloth error
–> how to avoid error
Not bothering to check
results/information for accuracy.
Incomplete evaluation.
Inadequate documentation.
--> conscientious: Attention to detail. Completeness. Not assuming that information presented to you is correct. Full documentation.
Fixation and loss of perspective error
Early unshakeable focus on a
diagnosis. Inability to see the
bigger picture. Overlooking
warning signs.
--> open mindedness, situational awareness: Recognition of the clinical patterns but considering facts that don’t fit. Reevaluation if deviation from the expected.
Communication breakdown error
Unclear instructions or plans. Not
listening to or considering others
opinions.
–> effective communication:
Being approachable and open. Listening. Clear explanation with
appropriate terminology and reinforcement.
Poor team working error
Team members working
independently. Poor direction.
Some individuals out of depth, others underutilised.
--> good team working: Clear team structure and roles with sharing of views, concerns and management plans. Clear logical leadership
Playing the odds error
Choosing the common and dismissing the rare event.
–> probability assessment:
Evaluation based on
scenario features as well and likelihood
Bravado (timidity) error
Working beyond your competence
or without adequate supervision. A
show of confidence to hide underlying deficiencies (not taking
on that which you should)
–> humility:
accurate self evaluation. open communication to mistakes.
Ignorance error
Lack of knowledge. Unconscious
incompetence. Not knowing what
you don’t know.
--> self-awareness : Aware of your own abilities and limitations. Consideration of factors which may affect your judgement (e.g., stress, fatigue)
Mis-triage error
Over/underestimating the
seriousness of a situation.
--> prioritisation: Appreciation of the relative importance or urgency of each situation.
Lack of skill error
Lack of approrpriate skills, teaching
or practice.
–> effective technical skills:
being properly trained in your role
System error
Environmental, technology,
equipment or organisational
features. Inadequate built in safeguards.
--> system design: A system designed to be easy to use, complete, and with design features that identify potential risk.
