Public Health 3 Flashcards
Error
Unintended outcome
Why is safety in healthcare so often compromised?
Complex
High-risk environment
Resource intensive
System, patient and practitioners’ interactions
Shared responsibilities
Practitioners unknowingly take risks
Common issues leading to accidents and safety in healthcare?
Wrong diagnosis = Wrong plan
Medication reconciliation
High concentration medication
Patient identification
Patient care handovers
Classification of errors
Based on intention
Based on action
Based on outcome
Based on context
Error based on intention
Failure of planned actions to achieve desired outcome
Skill-based errors - Action made was not intended
Rule-based mistakes - Incorrect application of a rule
Knowledge-based mistakes
Limited attentional resources
Memory containing mini-theories rather than fact
Error based on action
Generic factors
- Omission
- Intrusion
- Wrong order
- Mistiming
Task specific factors
- Wrong vessel/organ/side
- Bad knots
Error based on outcome
Near miss Successful detection and recovery Death/injury or loss of function Prolonged intubation - ICU Cost of litigation Unplanned transfer
Error based on context
Anticipations and perseverations
Interruptions and distractions
Team factors
Organised factors
Equipment and staffing issues
Nature of procedure
Accumulation of stressors
Person approach to error
Focus on the individual
- Error are the product of wayward mental processes
- Focuses on unsafe acts of people on the front-line
- Shortcomings - Anticipation of blame promotes cover-up
- Requires detailed analysis to prevent recurrence
System approach to error
Focus on working conditions
- Errors are commonplace - The product of many causal factors
- Remedial efforts directed at removing error traps and strengthening defences
- Interaction between active failures and latent conditions
- Protective risk management - Remedy latent factors
Tools of risk identification
Incident reporting Complaints and claims Audit, service evaluation and benchmarking External accreditation Active measures/compliance
Never events
Serious Largely preventable Patient safety incidents Should not occur IF available preventative measures have been implemented
Surgery - Wrong site, retained item
Medication - Wrong preparation or ROA
Mental health - Suicide
Leadership styles
Inspirational
Transactional
Laissez-faire
Transformational - Inclusive leadership is distributed throughout all levels of organisation
Sloth error
Not bothering to check results or accuracy of information
Incomplete evaluation
Inadequate documentation
How to prevent sloth errors
Conscientiousness
- Attention to detail
- Completeness
- Not assuming all information to be correct
- Full documentation
Fixation and loss of perspective error
Early unshakable focus on a diagnosis
Inability to see the bigger picture
Overlooking warning signs
How to prevent fixation and loss of perspective
Open mindedness
Situational awareness
Recognition of clinical patterns
But considering facts that don’t fit
Re-evaluation if deviation from the expected
Communication breakdown error
Unclear instructions or plans
Not listening to or considering others opinions
How to prevent communication breakdown error
Effective communication
Being approachable and open Listening Clear explanations Appropriate terminology Reinforcement
Poor teamwork error
Team members working independently
Poor direction
Some individuals out of their depth
Staff under-utilised
How to prevent poor teamwork
Clear team structure and roles
Sharing views, concerns and management plans
Clear logical leadership
Errors which occur by playing the odds
+ How to prevent
Choosing the common and dismissing the rare event
Probability assessment!
- Evaluation based on scenario features as well as likelihood
Bravado error
+ How to prevent
Working beyond your competence or without adequate supervision
A show of confidence to hide underlying deficiencies
Humility!
- Accurate self-evaluation
- Open communication of mistakes
Ignorance error
+ How to prevent
Lack of knowledge
Unconscious incompetence
Not knowing what you don’t know
Self-awareness!
- Awareness of your own abilities and limitations
- Considering factors which may affect your judgement - Stress/fatigue
Mis-triage error
+ How to prevent
Over-underestimating the seriousness of a situation
Prioritisation!
- Appreciate the relative importance of urgency in each situation
Lack of skill error
+ How to prevent
Lack of appropriate skills, teaching or practice
Effective technical skills - being properly trained!
System error
+ How to prevent
Environment Technology Equipment Organisational failures Inadequate built-in safeguards
System design!
- Easy to use
- Design features that identify potential risks
Swiss cheese model
Organisation’s defence against failure is a series of barriers
Represented as slices of swiss cheese
Holes in each slice represent weaknesses in parts of the system
Weaknesses are varied in size and position
Failure happens when holes from each slice momentarily align
“TRAJECTORY OF ACCIDENT OPPORTUNITY”
Hazard passes through the holes in all slices = Failure!
Causes of negligence
System failure
Human factors
Judgement failure
Neglect
Poor performance
Misconduct
Requirements for negligence to have occurs
- Duty of care?
- Breach in the duty of care?
- Did the patient come to harm?
- Did the breach cause the harm?
Money awarded for negligence claim
Loss of income
Cost of extra care
Pain and suffering
Different types of learner
Theorist - Complex, questions ideas, offers challenges
Activist - Experiences, extrovert, “deep-end”, leader
Pragmatist - Wants feedback, purpose, likes to copy
Reflector - Watches others, reviews work, analysis, collects data
Tripartite model approach to learning
Surface - Fear of failure, desire to complete a course, rote learning and focus on particular tasks
Strategic - Desire to be successful, leads to patchy and variable understanding
Deep approach - Intrinsic vocational interest or personal understanding - Making links across materials, searching for deeper understanding and general principles
Kolb’s learning cycle
- Experience - Activist
- Review and reflection - Reflector
- Conclusions - Theorist
- What can I do differently next time? - Pragmatist
Key responsibilities of small group tutors
Managing the group, activities and learning
Facilitator of learning
- Leading discussions
- Asking open-ended questions, guiding process and task
- Enabling active participation of learning
- Engagement with ideas
Fundamental questions to think about when teaching
Who - Numbers and level
What - Topic or subject - Type of learning expected
How - Method of teaching
Review - How will I know if students understood?
Different question strategies when teaching
Evidence Clarification Explanation Linking and extending Hypothetical Cause and effect Summary and synthesis
Model used to describe cultural factors
Iceberg model of culture
Above sea level - Gender, age, ethnicity
Below sea level…
- Socio-economic status
- Occupation and education
- Health
- Religion and cultural beliefs
- Social groupings
- Sexual orientation
- Political orientation
- Expectations and behaviours
Why do we need to learn about diversity
Better health outcomes for patients
More satisfying doctor-patient encounters
Culture
Socially transmitted pattern of shared meanings
Communicate, perpetuate and develop knowledge and attitudes
May be based on heritage, individual circumstance and personal choice
DYNAMIC!
Ethnocentrism
Tendency to evaluate other groups according to the values and standards of your own cultural group
With conviction that your group is superior
Stereotype
Generalisation
Typical characteristics of members of a group
Prejudice
Attitude towards another person
Based solely on their membership of a group
Discrimination
Positive or negative actions towards the object of prejudice
Kleinman’s explanatory model of illness
What do you call your illness?
What do you think caused it?
Why and when did it start?
What do you think the illness does?
How severe it is? How long does it last?
What kind of treatment do you expect?
What results do you want from the treatment?
What are the main problems caused by the illness?
What do you fear most about the illness?
Why have rationing needs increased
Shift from acute illness to chronic long-term
Normal physiological events being medicalised
Increased in choice
Increase in price of drugs
What is rationing
Resource refused due to lack of affordability
Rather than clinical ineffectiveness
Allocation theories
Egalitarian principles - Provide all care that is necessary and appropriate
- Tension between egalitarian aspirations and finite resources
Maximising principles - Criteria that maximises public utility
Libertarian principles - Everyone responsible for their own health, well-being and fulfilment
Rights engaged in healthcare
Article 2 - The right to life
Article 3 - The right to be free from inhuman and degrading treatment
Article 8 - The right to respect for privacy and family life
Article 12 - The right to marry and found a family
Risks of social media
Loss of personal privacy
Potential breaches of confidentiality
Online behaviour might be perceived as unprofessional, offensive or inappropriate
Risk of posts being reported by the media or sent to employers
GMC duties of a doctor
Make patient care your first concern
Protect and promote the health of patients and the public
Provide a good standard of care
Treat patients as individuals and respect their dignity
Work in partnership with patients
Be honest and open and act with integrity
