recognising error Flashcards
what is the duty of candour?
it is an obligation of all clinicians. They must report errors at an early stage so that lessons can be learned quickly and patients are protected from harm in the future
what is an adverse effect?
an injury resulting in prolonged hospitalisation, disability or death caused by healthcare management
what is a significant event?
it is an event thought by anyone in the team to be significant in the care of patients or the conduct or practice or organisation
what is a near miss?
it is an error that has the potential to cause an adverse event but fails to do so because of chance or because it is intercepted
what is a serious incident?
it is an unexpected or avoidable death or serious harm - a never event or a scenario that prevents or threatens an organisations ability to continue to deliver healthcare services
what types of incidents are there?
clinical - related to planning organisation, delivery, treatment or procedures
patient incidents that are no related to treatment
security incidents - theft etc
information governance incidents
staff incidents
what is the layout of the adverse event iceberg?
at the bottom of the triangle is unnoticed errors, near misses, errors considered insignificant which are all unreported
those that do get reported are errors that could or do cause harm
what is the freedom to speak up?
a culture that is safe, free to raise concerns, no bullying, facilitate the reporting of both formal and informal concerns, prompt, swift, proportionate, fair and blame free investigations
what is an increase in incidents?
it is not taken as an indication of worsening patient safety but rather as an increasing level of awareness of patient safety issues and more open and transparent culture
what is clinical risk management?
specifically concerned with improving the quality and safety of health care services by identifying the circumstances and opportunities that put patients at risk of harm and acting to prevent and control those risks
what is hazard and what needs to be considered?
it is things that could cause harm
consider how bad it would be, when it would happen and how urgently action needs to be taken
what is risk?
the likelihood that an incident would occur and how bad the consequences are
what is the risk matrix?
it is the likelihood score of 1-5
rare - extremely unlikely
unlikely - rare but not impossible - every 5 years
possible - fairly likely to occur - yearly
likely - every 6 months and more likely than not
almost certain - almost certain - monthly
also a consequence score
1 - no harm
2- minor - extra treatment or observation
3 - moderate - not permanent harm but need more treatment
4 - major - permanent harm
5 - catastrophic - death
how do you calculate the risk ?
multiply the consequence by likelihood scrore
what was a major event that lead to the national reporting and learning system?
the vincristine case
