PPS day - human factors, human rights and resource allocation Flashcards
Define patient safety
The coordinated efforts to prevent harm from occurring to patients, caused by the process of healthcare itself (WHO)
Name some human factors
Poor teamwork and leadership Tiredness Distraction Fixation Pressure and stress Poor situational awareness Unhelpful norms Poor communication Complacency Lack of knowledge Lack of resources
What is Heinrich’s triangle theory?
A triangle with tiers going from: unsafe acts to near misses, minor injuries, lost time injuries and fatalities
Most unsafe acts may not result in harm and a very small amount result in fatality
Define a never event
Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented
What are the impacts of a never event on a hospital trust?
Affects reputation
Results in financial penalty
Prompts visits by the CQC and Monitor and commissioners
Give examples of never events
Wrong site surgery Wrong implant Retained foreign object post-procedure Misplaced naso- or oro-gastric tubes Entrapment in bed rails Falls from windows Administration of medication via the wrong route Overdose of methotrexate or insulin
What should you do if a never event occurs?
Inform the appropriate people eg the Hospital patient safety team
As well as the CQC and National Reporting and learning system
What does the hospital patient safety team do?
- events are reported to them
- they investigate these events - the route cause, systems and processes and contributory factors
- Aim to learn from the problem, implement change and measure the change
What is the difference between a system level approach and a person approach?
System level approach - problems with patient safety are as a result of poor systems and processes and aims to identify root causes; Addresses the system to minimise the impact of human factors
Person approach - problems with patient safety are as a result of the actions of individual people
Give an example of a person and system approach to an incident involving wrong medication administration
Person approach - individual gave the wrong medication due to carelessness, tiredness, lack of knowledge etc
System approach - Medication with similar names being next to each other, controlled medications not stored separately
Give examples of system based changes that can be made to minimise the impact of human factors
- behaviour change
- culture surveys - eg asking staff whether the feel able to speak up, what factors are preventing you from doing your job to the best of your ability etc
- safety huddles
- simulation
- collaborative working
What are the main issues that result in patient safety concerns within the hospital?
- sepsis
- deteriorating patient
- falls
- pressure ulcers
- AKI
- end of life care
What are some of the common red flags that are the symptoms and signs of an evolving error chain?
Surpirses Ambiguities, anomalies Conflicting information Broken communication, confusion Inconclusive decisions Missing information, incomplete briefing Moving away from standard procedures and normal practice Fixation, Pre-occupation Time distortion and time runaway Unease, fear, stress Alarm bells ring in your mind Warning from equipment
What is the solomon asch experiment and what does it show?
Only one participant in a group and the others are actors taking part in an experiment - the actors all say the wrong answer until the participant also starts to say the wrong answer despite the fact that they don’t feel it is right
conformity - people will conform to the group - you might work with conformists who may not tell you what is going wrong in the group, may have a habit of migrating towards a wrong habit of working which become integrated into the culture
Give examples of commonly used safety tools
Surgical safety checklist
SBAR
