Pt Safe Flashcards
Root Cause 6 steps
Gathering information about an incident
Mapping information
Identifying problems
Analysing problems for contributory factors
Determining root causes
Developing recommendations and implementing solutions
Clinical Governance
“A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish
Pt Safety
“The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare.”
Medication Error
“Incident in which there has been an error in the process of prescribing, dispensing, preparing, administering, monitoring or providing medicines advice, regardless of whether any harm occurred.” (NPSA, 2007; p9)
Never events
Unacceptable & eminently preventable”
Risk management techniques:
Proactive
Failure Modes Effects Analysis
Risk management techniques:
Reactive
Root Cause Analysis
GPhC recommends a root cause analysis (RCA) is undertaken on dispensing errors (GPhC, 2010)
FMEA
“Systematic method of identifying and preventing process and product problems before they occur”
Step 1: Graphically describe process
Step 2: List failure modes (what could go wrong) for the process, rank the severity and probability of each failure mode
Step 3: List causes of failure modes
Step 4: Design interventions for failure modes
Step 5: Identify outcome measures for interventions
Step 6: Implement and monitor interventions
RCA definition
“a structured investigation that aims to identify the true cause of a problem and the actions necessary to eliminate it.”
Reason’s Accident Causation Model is divided into 4
- Latent failure - management and oraganisational
- Error producing conditions eg. team factors
- Unsafe acts - slips, lapses
4 Barriers overcome —- incident
