SAFETY 1 + SAFETY 2

Question 1

Where do medication errors occur?

Answer 1

1. Care homes
2. Primary care
3. Secondary care

Question 2

Why do medication errrors occur?

Answer 2

1. Administration
2. Prescribing
3. Dispensing
4. Monitoring
5. Transitioning between medicines

Question 3

NHS patient safety strategy

Answer 3

1. Insight
2. Involvement
3. Improvement

Question 4

Insight

Answer 4

• Measurement
• Incident response
• Medical examiners
• Alerts
• Litigation

Question 5

Involvement

Answer 5

• Patient safety partners
• Curriculum and training
• Specialists
• Safety II

Question 6

Improvement

Answer 6

Improveme programmes to enable effective and sustainable change in the most important areas

Question 7

Reactive approach

Answer 7

• After the event
• Report/record incidents
• MHRA – Yellow Card reporting

Question 8

Reporting incidents - HCP

Answer 8

• Record on their local risk management systems (LRMS).
• LFSE is a new approach being trialled.

Question 9

LFSE

Answer 9

• Learn from patient safety events
• Central service for recording and analysis of patient safety events that occur.
• In the final stages of development

Question 10

Root cause analysis (RCA)

Answer 10

• Evidence-based, structured investigation
• Identify cause of incident, and actions needed to prevent it happening again.
• Understand what, why and how a system failed

Question 11

RCA process

Answer 11

1. Identify incident
2. Gather information & map incident
3. Identify care & service delivery problems
4. Analyse problems & identify CFs and RCs
5. Generate solutions & recommendations
6. Implement solutions
7. Write the report

Question 12

Disadvantages of RCA

Answer 12

• Simplistic
• Typically completed with very limited resources and time frame.
• Does it take a systems approach?

Question 13

What is a system?

Answer 13

• Inter-related entities and people with a joint purpose
• Entities = buildings/ spaces/ software etc

Question 14

What is the primary benefit of a dynamic system?

Answer 14

Modified in response to circumstances, to achieve the same outcome

Question 15

What type of system is Healthcare?

Answer 15

A complex socio-technical system

Question 16

How do you gather information on how well a system is running?

Answer 16

• 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

Question 17

How can you analyse data obtained from gathering information?

Answer 17

• Thematic analysis
• Systems framework

Question 18

What is the SAFETY-1 definition of ‘safety’?

Answer 18

• As few things as possible go wrong
• Safety management principle: Reactive
• Humans seen as a liability or hazard

Question 19

What is the role of performance variability in SAFETY-1

Answer 19

Harmful - should be prevented

Question 20

What are the assumptions of SAFETY-1?

Answer 20

• 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)

Question 21

SAFETY-1: Find and fix

Answer 21

• 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)

Question 22

What is the SAFETY-2 definition of ‘safety’?

Answer 22

As many things as possible go right

Question 23

What is the safety management principle of SAFETY-2?

Answer 23

Proactive

Question 24

What is the view of performance variability of SAFETY-2?

Answer 24

Inevitable but also useful

Monitored + managed

Question 25

What is a resilient healthcare?

Answer 25

• 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

Question 26

What are they key capacities of resilient healthcare?

Answer 26

(1) Respond
(2) Learn - share from past experiences
(3) Monitor
(4) Anticipate

Question 27

Key concepts of SAFETY-2

Answer 27

• 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

Question 28

How is patient safety defined in general?

Answer 28

Maximising the tings that go right and minimising the things that go wrong

Question 29

just read over

Analysing and improving systems

Answer 29

• 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

Question 30

jus tread over its waffl

SAFETY-2 interventions

Answer 30

• 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