Red Book - Critical Incidents Flashcards
What is a patient safety incident
Any healthcare event that is:
Unexpected Unintended Undesired Associated with acutal OR potential harm
Why are critically ill patients at greater risk
High invasive treatments with complications
Frequent interventions
Freqent and many drugs and infusions
No capacity/autonomy
Lack of physiological reserve
Cannot communicate concerns
Busy/crowded
Stages of delivering a medication
Prescription
Transcription
Prepare
Dispense
Admin (most errors are here)
What is a medical error
Any mistake in the prescription
Preparation
Admin
Of a drug
Does not neeccessarily cause harm.
What is an Adverse Drug Event
A medication error with harm occurs
Why are medication errors common on ICU
Patient - Severe illnes, extremes of age, prolonged hospital stay, sedated and lacking capacity, polypharmacy, changes to pharmacodynamics/kinetcs
Environment - patient and staff turnover, stress conditions, emergencys, communication issues
Medicine - many, pumps, infusions, weight estimation
What is a never event
Serious incident…
Wholly preventable….
As there is guidance or safety recommendations
That provide strong and systemic barriers
Available at the national level
And SHOULD have been implemented by all heathcare providers
Name never events
Surgical - Wrong site
Wrong implant/prosthesis
Retained foreign body post op
Medication - Wrong potassium solution
Wrong route of admin
Insulin oversdose - wrong device, use of abbreviation
Methotrexate overdose (non cancer)
Mis-selected high strength midaz for concious sedation
Mental heath - failure to instal collapsible shower/curtain rails
General - fall from windown chest/neck trapped in bed rails ABO incompatible transfusion NG tube misplacement Scalds
What can help prevent/minimise a never event
1) two person checks of blood/drugs/STOP before you block
2) Barcode scanners
3) Checklists, WHO, etc
4) debriefs
5) standardised process, LOCSIP, NATSIP
6) team traning and awareness of human factors
7) manadatory training
8) culture of open communication
Principles of the NPSA NG guidnace
1) NOTHING should go down an NG until position confirms
2) First line - pH. 1 to 5.5.
Test strip must provide clear dilneation between 5.5 and 6
Document pH
NO LITMUS
3) second line. CXR - no aspirate or pH not in range
Who ordered/authorised xray
who confirmed position
check its right xray, most recent
What happens if you have a never event
1) IT NEEDS TO BE REPORTED
2) maintain patient safety, stabilise the patient, and treat complications
3) Tell responsible consultant and head of dept
4) Candour, tell patient and family ASAP
5) Incident form
Report on the Strategic Executive Infor System
6) tell relevent commisioner as per Serious Incident Framework
7) investigate, and do an RCA
8) Declare on Form R.
