SAFETY 1 + SAFETY 2 Flashcards
Where do medication errors occur?
- Care homes
- Primary care
- Secondary care
Why do medication errrors occur?
- Administration
- Prescribing
- Dispensing
- Monitoring
- Transitioning between medicines
NHS patient safety strategy
- Insight
- Involvement
- Improvement
Insight
- Measurement
- Incident response
- Medical examiners
- Alerts
- Litigation
Involvement
- Patient safety partners
- Curriculum and training
- Specialists
- Safety II
Improvement
Improvement programmes to enable effective and sustainable change in the most important areas
Reactive approach
- After the event
- Report/record incidents/patient safety events
- MHRA – Yellow Card reporting
Reporting incidents - HCP
- Record on their local risk management systems (LRMS).
- LFSE is a new approach being trialled.
LFSE
- Learn from patient safety events
- Central service for recording and analysis of patient safety events that occur.
- In the final stages of development
Root cause analysis (RCA)
- Evidence-based, structured investigation
- Identify cause of incident, and actions needed to prevent it happening again.
- Understand what, why and how a system failed
RCA process
- Identify incident
- Gather information & map incident
- Identify care & service delivery problems
- Analyse problems & identify CFs and RCs
- Generate solutions & recommendations
- Implement solutions
- Write the report
Disadvantages of RCA
- Simplistic
- Typically completed with very limited resources and time frame.
- Does it take a systems approach?
What is a system?
- Inter-related entities and people with a joint purpose
- Entities = buildings/ spaces/ software etc
What is the primary benefit of a dynamic system?
Modified in response to circumstances, to achieve the same outcome
What type of system is Healthcare?
A complex socio-technical system
How do you gather information on how well a system is running?
- Investigative interviews: engaging those affected by patient safety incidents
- Observations/site visit/reconstruction/sketch site of incident/photos
- Documentation review: patient records, policies, guidelines
- Physical equipment e.g. medical devices, communication
systems etc - Interviews with other relevant stakeholders
How can you analyse data obtained from gathering information?
- Thematic analysis
- Systems framework
What is the SAFETY-1 definition of ‘safety’?
- As few things as possible go wrong
- Safety management principle: Reactive
- Humans seen as a liability or hazard
What is the role of performance variability in SAFETY-1
Harmful - should be prevented
What are the assumptions of SAFETY-1?
- Assumes that things that go right and wrong happen in different ways
- Assumes that function (work as imagined) results in success (no adverse effects)
- Assumes that malfunction (non compliance, error) results in failure (accidents, incidents)
SAFETY-1: Find and fix
- Solutions usually involve changing human behaviour
- Transfer learning from other industries
- Problems can be clearly defined and a technique/tool/etc would be able to fix it.
- Find general laws and empirical knowledge to base actions/interventions
- More accountability – doing the right thing
- Interventions have a predictable linear effect (stability of cause and effect relationships)
What is the SAFETY-2 definition of ‘safety’?
As many things as possible go right
What is the safety management principle of SAFETY-2?
Proactive
What is the view of performance variability of SAFETY-2?
Inevitable but also useful
Monitored + managed
