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
Improveme programmes to enable effective and sustainable change in the most important areas
Reactive approach
- After the event
- Report/record incidents
- 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
What is a resilient healthcare?
- Intrinsic ability of a system or an organisation to change the way it functions
- Prior to, during, or following changes and disturbances
- To sustain required operations
- In expected and unexpected conditions
What are they key capacities of resilient healthcare?
(1) Respond
(2) Learn - share from past experiences
(3) Monitor
(4) Anticipate
Key concepts of SAFETY-2
- Input variability
- Work as imagined (WAI) and work as done (WAD)
- Functional resonance
- people make approximate adjustments ie adaptation and flexibility under pressure/challenges within acceptable levels
- Emergent rather than causal
- successful outcomes dependent on context
How is patient safety defined in general?
Maximising the tings that go right and minimising the things that go wrong
just read over
Analysing and improving systems
- Systems analysis and understanding
- Methods and tools e.g. Functional Resonance Analysis Method (FRAM), resilience analysis grid, cognitive work analysis, resilience markers framework, etc
- WAI: methods e.g. interviews, focus groups, documents, etc
- WAD: methods e.g. ethnography, observations (direct, video) etc
- Accident analysis methods
- Resilience frameworks
jus tread over its waffl
SAFETY-2 interventions
- Team training to deal with short term disruptions
- Making adaptations more visible and more easily monitored
by re-designing documentation used - Regular huddle between different professionals to exchange information about patients to ensure timely assessment, and forward planning
- Improved documentation or an electronic artefact to allow for shared monitoring
