Risk and Errors

Question 1

Define a medication error

Answer 1

Department of Health (2004)’s definition:

“A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer.”

Question 2

What is the Root Cause Analysis?

Answer 2

1. Evidence-based & structured investigation
2. Aim to identify true cause of a problem and the actions needed to eliminate it
3. Understand what, why and how a system failed

Question 3

Describe the RCA process? (7)

Answer 3

1. Identify incident
2. Gather information and map the incident (timeline of events)
3. Identify care & service delivery problems
4. Analyse problems (brainstorming, nominal group technique)
5. Generate solutions and recommendations
6. Implement solutions
7. Write report

Question 4

When to conduct a RCA?

Answer 4

1. After a serious incident

2. After a series of incidents or near misses

Question 5

What is the nominal group technique?

Answer 5

Ideas discussed and rationalised, ranked 1-5, prioritised by ranking scores

Question 6

What is the 5 whys technique involve?

Answer 6

Asking “why is that” 5 times

1. What is happening?
   then why is that ….

Question 7

What is the Swiss Cheese Model?

Answer 7

Successive layers of defences, barriers and safeguards. There are holes in each layer representing what could have allowed something to go wrong such as latent conditions, unsafe acts, organisation issues.

Leading to failed defences

Question 8

What is the Reason’s Organisational Accident Model?

Answer 8

Integrated framework.
Based on the error theories described above Vincent and colleagues created a framework for the analysis of adverse events and critical incidents in healthcare.This framework includes active failures, error and violation producing conditions, and latent conditions.

Question 9

What are the key principles for solution design? (6)

Answer 9

1. Simplify tasks, processes and protocol
2. Standardise processes and equipment
3. Minimise dependency on short-term memory and attention span
4. Avoid fatigue
5. Improve reliability in delivery of quality care
6. Retraining is not always the right solution

Question 10

What are some of the limitations to a RCA? (5)

Answer 10

1. Time consuming
2. Difficult to achieve involvement
3. Difficult to be blame free
4. Bias – cognitive,hindsight, outcome
5. Memory degradation

Question 11

Explain what cognitive, hindsight and outcome bias is?

Answer 11

1. Acognitive biasis a mistake in reasoning, evaluating, remembering, or other cognitiveprocess, often occurring as a result of holding onto one’s preferences and beliefs regardless of contrary information.
2. Hindsight bias, also known as the knew-it-all-along effect or creeping determinism, is the inclination, after an event has occurred, to see the event as having been predictable, despite there having been little or no objective basis for predicting it.
3. Theoutcome biasis an error made in evaluating the quality of a decision when the outcomeof that decision is already known.

Question 12

Describe what human factors encompass

Answer 12

All those factors that can influence people and their behaviour.

In a work context, human factors are the environmental, organisational and job factors, and individual characteristics which influence behaviour at work

Question 13

How do you use human factors to reduce errors

Answer 13

Have to accept that a vast majority of people come to work to do a good job

Mistakes are usually caused by ineffective systems not bad people

Systems should be designed to do the right thing

Create a culture where human error is seen as a source of important learning

Taking responsibility for safety whoever we are, where ever we are

Question 14

Describe what is safety I

Answer 14

Definition- As few things as possible go wrong

Safety management principle- Reactive

Explanation of accidents- caused by failures and malfunctions, purpose of investigation identify causes and contributory factors

Attitude to the human factor- humans as a liability or hazard

Role of performance variability- harmful- should be prevented as far as possible

Question 15

What is the root cause analysis process and describe it

Answer 15

Identify incident

Gather information and map incident

• Investigate interviews, those involved, witnesses
• Site visit/reconstruction/ Sketch site of incident with photos
• Documentation review- gather documents and written accounts
• Equipment quarantine where appropriate
• Organise all information into chronological timeline and resolve gaps or inconsistencies with timeline

Identify care and service delivery problems
- swiss cheese model- holes due to active failures

Analyse problems and identify CFs and root causes

• Brainstorming or brain writing
• 5 way’s keep asking why did this happen?
• Fishbone- patient factors, individual, task factors, communication factors, team factors, education or training factors, equipment + resources, working condition factors, organisational and strategic factors = problem or issue

Generate solutions and recommendations
- Stronger actions- change cultural approach
- Moderately strong actions- effective use of skill mix
- Weaker actions- double checks, warning labels
Effectiveness is higher from weaker actions
- Simplify tasks, processes and protocols, standardise processes and equipment, avoid fatigue,

Implement solutions

• Respond to incidents
• Increase confidence or create fear?
• Identify weakness

Write the report

Question 16

What important questions must be asked in the prospective methods of risk assessment

Answer 16

What can go wrong
How bad
How often
Is there a need for action

Question 17

Why do risk assessment? (6)

Answer 17

1. Help improve work and care delivered
2. Balance risk reduction with supporting innovation
3. Support better decision making
4. Helps plan for uncertainty
5. Increase patient and public confidence
6. Highlights weaknesses in procedures, practices and policy changes

Question 18

What factors depend on when you do root cause analysis?

Answer 18

Degree of harm or damage caused at the time

Realistic future potential for harm if it occurred again

Better to do fewer RCAs well than consider it as an ending in its own right

Question 19

How is risk assessment associated with purchasing for safety?

Answer 19

Risk assessment of products as part of healthcare contracting and purchasing

Safety before price, purchase products with following:

• Clear labelling and packaging
• Well differentiated similar products to prevent misidentification
• Appropriate secondary and warning labels
• Bar codes
• Ready to administer/use or simple preparation and administration
• Adequate information for practitioners, patients and carers

Question 20

What is the failure modes and effects analysis (FMEA)?

Answer 20

Systematic proactive method for evaluating a process

Identify where and how it might fail

Assess relative impact of different failures

Identify parts of the process that are most in need of change

Question 21

What does FMEA do, when do you use it and what does it identify?

Answer 21

What does it do
- Identify potential points of failure and effect on individuals and organisations

When to use it
- Useful for new process and process change

What does it identify

• Process
• Failure mode- what could go wrong
• Failure cause- why it could go wrong
• Failure effect- consequences of failure

Question 22

What is the risk matrix?

Answer 22

When all actions should be directed towards achieving optimal reduction in severity and/or likelihood

Result = a collective perception of risk rather than a precise, objective measure of risk, but as such still VERY valuable.
Objectivity and precise science may be difficult in many areas and this provides a valuable and valid means of working with and communicating about risk in that arena.

Question 23

What are the benefits (5) and constraints (2) of FMEA?

Answer 23

Benefits:
Improved design

Multidisciplinary

Systems based

Systematic, thorough, consistent

Ensure care is fit for purpose

Constraints:
Time consuming

Frustrating

Question 24

What interventions can you have for prescribing

Answer 24

Tools:
Electronic prescribing and computerised decision support

Education:
Training
Audit, reporting systems
Improvement projects

Professional roles:
Pharmacists

Question 25

What is safety II

Answer 25

Definition: As many things as possible go right

Safety management principle: proactive

Explanation of accidents: Activities happen in the same way, regardless of outcome
How things go right to explain how things go wrong

Attitude to the human factor: humans as a resource, flexibility and resilience

Role of performance variability- inevitable but also useful, monitored

Why and how things go right

Safety as an emergent property of a resilient healthcare organisation

Question 26

Describe what is organisation resilience

Answer 26

Property of working environment

Ability to cope and respond to demands effectively

Creating environments so patient care can take place safely

4 key capacities: RLMA

• Respond: how and when- resources
• Learn- past experiences and share that knowledge
• Monitor- what, reliability and continuous
• Anticipate- uncertainties

Question 27

What is the difference between Risk assessment and RCA?

Answer 27

Risk Assessment:
Prospective
Identify risks
Plan for uncertainty (during change)
Highlight weakness
Improve care standard generally
Increase patient & public confidence

RCA:
Retrospective
Identify incident causes
Respond to serious incidents or themes
Identify weakness
Reduce risk of future errors occurring
Depend on incident reporting
Time consuming – choose wisely