Professional Behavior Flashcards
Errors in practice
- Sloth error: being lazy, not bothered to check results/information for accuracy
- Lack of skill: Lack of appropriate skills or teaching in practice
- Communication breakdown: Unclear instructions or plans and not listening to others
- System failure: Machine/equipment stopped working
- Human factors: bravado, timidity
- Judgement failure
- Neglect
- Poor performance
- Misconduct
Error classification
Intention: failure of planned action to reach desired action
Action: task specific
Outcome: Near miss or death
Context: Interruptions, team factors
Strategies to prevent error
- Team training
- Checklists
- Simplification and standardisation of clinical practice
4 aspects of Negligence
- Was there a duty of care?
- Was there a break in that duty
- Was the patient harmed?
- Was the harm due to the breach in care?
Bolam and bolitho rules
Bolam: Would a group of reasonable doctors do the same?
Bolitho: Would that be reasonable?
Never event definition
Serious, largely preventable patient safety incidents, should not occur if the available preventable measures have been implemented
Person vs systems approach
Person - hold one person accountable
Systems - identify there are latent errors in the system
Swiss cheese model of error
Falling through the holes because there is failed or absent defences against error happening. These are called LATENT FAILURES.
Organisational influence → Unsafe supervision → preconditions for unsage acts → unsafe acts
Bucket model of error
SELF = Poor knowledge, fatigue, little experience/skill, feeling unwell
CONTEXT = distraction, poor h andover, lack of team support, equipment
TASK = errors, take complexity, new task, process
Duty of candour
Every healthcare professional must be open and honest with patients when
something that goes wrong with their treatment causes, or has the potential to cause, harm or distress.
