recognising error in healthcare Flashcards
what is a serious incident?
it is unexpected or avoidable death of patients, staff or public. There is serious harm caused to individual(s) that required life saving intervention, surgery or medication and results in permanent harm, shortens LE or results in prolonged physical or psychological pain
what is another definition of a serious incident?
a scenario that prevents or threatens to prevent an organisations ability to continue to deliver healthcare services due to actual or potential loss of personal/organisational information, damage to property, reputation or the environment or IT failure, allegations of abuse or adverse media coverage or public concern about the organisation
what are never events?
wrong site of surgery, wrong implant, overdose of methotrexate in non cancer patients, wrong place nasogastric feeding tube, retained foreign object post procedure, wrong route of medication, wrong dose of insulin due to abbreviation or incorrect device, transfusion of incompatible blood components, maladministration of potassium containing solutions and patients head or neck entrapment in bed rails, wrong dose midazolam during sedation, failure to install collapsible showers, falls from badly restricted windows and scalded patients
what is the SI process?
serious incident process to identify and change what went wrong
what is the course of a SI process?
identifying and responding, communicating to the healthcare professionals and patients, reporting and analysing through RCA in a timely manner, action planning after CCG review and response, developing, agreeing and implementing, disseminating learning and monitoring
how do we identify contributing factors?
what were the critical problems, what were the main contributing factors or root causes and what needs to be done
what is RCA?
it is root cause analysis
what does RCA comprise?
timeline, swiss cheese model, contributory factors and react, record and repsond
what does the swiss cheese model identify?
active and latent factors
what comprises contributory factors?
the organisational accident model and the fishbone diagram
what is the swiss cheese model?
where the slices are the barriers to preventing an incident, there are holes which are latent or active factors and if all these holes line up then a incident will occur
what is the organisational accident model?
it shows how accidents occur. It starts with the organisation (management decisions and organisational processes) then the workplace (error and violation producing conditions) then the person or team (errors and violations) then defences and inadequate barriers. Individually each of these categories can also lead to a latent failure pathways
what is the fishbone diagram and what does it show?
it is to identify a cause an effect of an incident - the centre line is budgets and things submitted late or wrongly, and there are six lines coming off - people, material (no spreadsheet or standards to refer to), method, machine (manual, systems availability), measurement (no milestones and units) and environment
what should a timeline include?
date and time, key events, supplementary information. other issues and good practice
what should a contributory factor analysis include?
contributory factors and why they happened and if they were the main root cause and other problems to tackle and why they happened
what does action planning comprise and what is the aim?
the aim is to write up an action plan to implement the recommendations and this will include areas of good practice and developing a list of targeted recommendations and developments to rectify each factor
what is the NEWS?
the national early warning score that was designed by NCEPOD and NICE in 2007 as a robust system to monitor each patients condition and what to do - track and trigger
what does NEWS depend on?
the accuracy of the observations, the person taking them, the escalation and action when the score goes up and timely manner
what is a score 0?
it is when the patient is stable with a minimum of BD observations
what is a score of 1-4 implicating?
more frequent observations that are dictated by a registered nurse of around 4 hourly and monitoring the output of urine on a chart
what does a score of 5 overall or a score of 3 or over in any of the parameters mean?
registered nurse to assess every 2 hours, check blood glucose, contact FY2 and reg for review in 30 minutes, alert NIC, strict fluid balance input and output hourly, alert screen for severe sepsis and start treatment if needed
what does a score of 7 mean?
inform the nurse who must immediately assess and request immediate reg review, increase observations to hourly for at least 6 hours, strict fluid balance of hourly intake and output, reg to discuss with consultant and critical care outreach team
what is SBARR?
it is a means of communication - situation, background, assessment, recommendations and review/response
what is the aim of RCA and serious incident analysis?
to learn from and share within national level to avoid never events
