Risk management Flashcards
1
Q
Clinical governance
A
- Essential service of the NHS contract framework
- Risk management
- Every pharmacist has the responsibility of being aware of risks associated with their work
2
Q
Managing risk
A
- No single solution to cover all circumstances
- Balance all factors (known and unknown)
- Everyone’s perception and management of risk depends on viewpoint, experience and circumstances
3
Q
Importance
A
- Patient safety and wellbeing
- Safeguard oourselves, colleagues and public
4
Q
What is a hazard, what is a risk
A
- Hazard
- Source of harm, categorised in how they can cause harm
- Physical
- Chemical
- Biological
- Ergonomical/psychological
- Risks
- Probability of hazard manifesting into harm
- Probability X severity
5
Q
Hazard leading to harm
A
- Wrong medicine taken by wrong patient leading to adverse effects/hospitalisation/death
- Needle stick injury
- Stress due to heavy workload
- StaffCustomer trip and falls from slippery wet floor
- Prescribing the wrong medication/wrong dose
6
Q
Common errors
A
- Incorrect prescriptions
- Formulation mismatch
- Constriants due to technology
- Illegible handwritten prescriptions
7
Q
NRLS
A
- National reporting and learning system
- Classify incidents as
- No-harm
- Low
- Moderate
- Severe
- Death
8
Q
Who to report to
A
- Patient involvement- NRLS
- Staff- HSE (Health and Safety Executive)
- HSE definitions
- Accident- results in injury/ill health
- Incident- near miss or undersired circumstance
- Dangerous occurence- one of a number of reportable adverse events defined in RIDDOR
9
Q
RIDDOR
A
- Riddor- Reporting of Injuries, Disease and Dangerous Occurrences Regulation
- RIDDOR puts duties on employers, the self-employed and people in control of work premises (the respobsible person) to report certain serious workplace accidents, occupational disease and specified dangerous occurrences
- Includes needle stick injury to staff and transmission of BBV (Blood Borne Viruses)
10
Q
Reporting
A
- Learn from mistakes
- Shape policies
- Identify training needs
- Workplaces have their own reporting systems
- Allows to identify trends
- NHS hot on it-now part of new contracts- annual patient safety report
11
Q
Human Error
A
- Not intended by the actor; not desired by a set of rule or an external observer; or that led the task or system outside its acceptable limits
- Knowledge base behaviours (when already familiar with many of the basic skills and rules in the setting)
- Rule based behaviours (follow simple rules about how to proceed with a task)
- Skill based behaviours (When someone does a familiar task, in a way it has become an automatic task)
12
Q
Violations
A
- Deliberately deviating from rules policies procedures
- Taking short cuts
- Laziness
- Lack of training
- Ignorance
- Unconscious incompetence
13
Q
Swiss cheese model of accident causation
A
14
Q
Blame
A
- Single person balme
- Multiple chain of events or catalogue of errors that lead to a negative outcome
- NHS is branded as an no-blame culture- duty of candour
- Culture of fair blame, openness and transparency
- (further advice if negligence/Malicious intent to harm)
15
Q
Root cause analysis
A
- Getting started
- Gathering and mapping information
- Identifying care and service delivery problems
- Analysing to identify contribution factors and root causes
- Gathering solutions
- Log, audit and learn from investigation reports
16
Q
Significant event audit
A
- Describe what happended and any issues arising from the significant event
- Describe what went well, what went less well and what could be done differently next time
- Describe what you learn from the event
17
Q
Risk assessment
A
- Involve your team and get their input into the process and feedback on your analysis and conclusions
- Read previous error reports and or workplace logs or diaries
- Talk to colleagues in other organisations
- Read journals and resources relating to risks both in pharmacy and in other professions and settings
- Complete an audit
- Ask your patients for feedback
18
Q
Managing risk
A
- Mitigate- common risk management strategy one will consider to bringthe risk to a level that is seen to be acceptable
- Avoid- avoid all actions leading to the risk
- Transfer- insurance against risk. Professional indemnity. Employers liability
- Accept- you accept there is a risk but do nothing about it to avoid it
19
Q
Control measures
A
- Eliminate risk- choose an option that does this
- Substitute- choose a lower risk option
- Engineering- contain the risk physically i.e. click cloc containers for meds
- Administrative- having policies, procedures or SOP’s in place
- PPE- Personal Protective Equipment
20
Q
A
21
Q
Example of assessing risk
A
