Responding to errors Flashcards
What is an adverse drug event?
An injury or harm caused by using a drug, even if it was used correctly.
What is medication error?
Preventable event that can cause inappropriate medication use or patient harm.
When can medication errors occur?
- Prescribing
- Dispensing
- Administering
- Labelling
- Monitoring
What is a medication-related harm?
Harm caused by a medicine if taken incorrectly, monitored insufficiently or due to a communication problem.
What is patient harm?
An incident which harms the patient
-> not their condition
What are the 2 things to know if a medication-related harm is preventable?
- Modifiable cause
- Harm could have been prevented if guidelines where followed
What is moderate harm?
- Requires moderate increase in treatment
- No permanent harm
What is severe harm?
- Permanent damage
-> Related to incident and not the condition
What are the 7 key parts of responding to patient safety incidents?
- Reflect
- Be open and honest
- Review
- Record and Report
- Act
- Share learning
- Evaluate
What is the REFLECT part of the responding to patient safety incidents?
Regularly check knowledge, understanding and systems to identify gaps
-> improve safety and outcomes
What is the BE OPEN AND HONEST part of the responding to patient safety incidents?
Duty of Candour
- Tell patient something went wrong
- Apologise
- Offer remedy/support
- Explain short and long-term effects
What is the REVIEW part of the responding to patient safety incidents?
- Investigate all incidents (+near misses)
- Use Root Cause Analysis (RCA) to identify areas for improvement.
What is the RECORD AND REPORT part of the responding to patient safety incidents?
Record and report everything
What are the 3 things that all healthcare professionals should report?
- ADRs (Yellow card scheme)
- Medical device adverse incidents
- Defective or counterfeit medicines and medical devices
What is another thing that can be used to record patient safety events?
LFPSE - Learning from Patient Safety Events
What is the ACT part of the responding to patient safety incidents?
Change/improve quality of practice/systems to prevent problems from reoccurring
What are the 5 things the Care Quality Commission (CQC) has produced on solutions to prevent harm?
- Prioritise serious incidents
- Involve patients/families
- Support staff involved
- Focus on underlying causes (system) rather than staff
- Identify human factors
What is the incident log for all incidents called?
Near miss error log.
What is the SHARE LEARNING part of the responding to patient safety incidents?
Share learning with relevant individuals to improve patient safety and minimise risks.
What is the EVALUATE part of the responding to patient safety incidents?
Regularly checking systems and practice to prevent future risks and patient safety incidents.
