PPS Flashcards
Never events
Adverse events that should never have happened.
Examples of never events
Wrong surgery site Overdose of insulin Wrong route of drug administration Entrapment in bedrails Incompatible transfusions
Swiss cheese model of adverse events
Each slice of cheese is a barrier to stop error happening or propagating, however, are holes in system allowing errors to keep going.
Test used to assess medical negligence
Bolam test
4 steps to negligence
There was a duty of care to the patient from the doctor.
This duty of care was breached.
The patient came into harm,
The harm caused was due to the breach in the duty of care.
Bolam test
Would a group of reasonable doctor act the same?
Bolitho test
Is the action logical and reasonable?
3 duties of a doctor
Knowledge, skills and performance - patient is first priority.
Safety and quality - report concerns.
Maintain trust - be honest and open and act with integrity.
Neglect
Below standard care, repeated minor mistakes, not caring.
Misconduct
Deliberate harm.
Name 2 theories of clinical decision making
Dual process theory.
Intuitive decision-making.
Name 4 types of error
Sloth (not conscientious)
System error (technological, poor design)
Communication break down
Playing the odds (poor probability assessment)
Person error
Error due to mental process of an individual with unsafe actions from the person
System error
Error due to design of system, is more commonplace.
