SAFETY 1 + SAFETY 2 Flashcards
1
Q
Where do medication errors occur?
A
- Care homes
- Primary care
- Secondary care
2
Q
Why do medication errrors occur?
A
- Administration
- Prescribing
- Dispensing
- Monitoring
- Transitioning between medicines
3
Q
NHS patient safety strategy
A
- Insight
- Involvement
- Improvement
4
Q
Insight
A
- Measurement
- Incident response
- Medical examiners
- Alerts
- Litigation
5
Q
Involvement
A
- Patient safety partners
- Curriculum and training
- Specialists
- Safety II
6
Q
Improvement
A
Improvement programmes to enable effective and sustainable change in the most important areas
7
Q
Reactive approach
A
- After the event
- Report/record incidents/patient safety events
- MHRA – Yellow Card reporting
8
Q
Reporting incidents - HCP
A
- Record on their local risk management systems (LRMS).
- LFSE is a new approach being trialled.
9
Q
LFSE
A
- Learn from patient safety events
- Central service for recording and analysis of patient safety events that occur.
- In the final stages of development
10
Q
Root cause analysis (RCA)
A
- Evidence-based, structured investigation
- Identify cause of incident, and actions needed to prevent it happening again.
- Understand what, why and how a system failed
11
Q
RCA process
A
- 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
12
Q
Disadvantages of RCA
A
- Simplistic
- Typically completed with very limited resources and time frame.
- Does it take a systems approach?
13
Q
What is a system?
A
- Inter-related entities and people with a joint purpose
- Entities = buildings/ spaces/ software etc
14
Q
What is the primary benefit of a dynamic system?
A
Modified in response to circumstances, to achieve the same outcome
15
Q
What type of system is Healthcare?
A
A complex socio-technical system
