SPR L3 Reducing Error + Ensuring Patient Safety

Question 1

Outcomes

Answer 1

1. Define error and safety and the scope of and most common types of medical error in the health and social care system.
2. Discuss factors which influence safety in a health and social care system.
3. Outline different mechanisms to improve safety and reliability in a HSC system and some methods of investigating errors in the NHS.
4. Discuss individual and organisational accountability and systems of governance to safeguard quality.
5. Explain the main types of diagnostic error in primary care

Question 2

Common types of error

Define an ‘error or adverse incident’

Answer 2

any event or circumstance that could or did lead to harm, loss or damage to people, property environment or reputation

Question 3

Common types of error

What are the common types of error?

Answer 3

Medication error – most common preventable cause of patient injury.

Missed/delayed diagnosis – e.g. failure to recognise a patient is seriously ill

Perioperative – e.g. needless infection, wrong site, wrong side, wrong patient, lack of DVT prophylaxis

Question 4

Common Types of Error

Healthcare isn’t as safe as it should/could be despite best intentions of a dedicated & highly skilled workforce.

Discuss this statement

Answer 4

• Unintended harm and unnecessary deaths are an all too frequent outcome of pressurised healthcare systems.
• 30-40% of patients do not receive care in line with current scientific evidence.
• Adverse events occur in 10% of NHS admissions & >50% are preventable.

Question 5

Why do things go wrong?

Answer 5

Failure to recognise

Failure to rescue/act

Failure to plan

Failure to communicate

Variation in clinical practice

Question 6

The estimated scale of the problem

1. Outline the problem in PRIMARY CARE
2. What are 50% of clinical negligence cases due to?
3. give examples of other common errors

Answer 6

1. >70% of patients’ contact with the NHS is in the community and each day. Wide variation in error rates - varying from 5-80 per 100,000 consultations
2. a failure or delay in diagnosis
3. medication prescription errors, failure or delay in referral, failure to warn of or recognise side effects of medication.

Question 7

1. What is the perception surrounding errors?
2. What is ‘the perfection myth’
3. What is ‘the punishment myth’
4. What are the realities?

Answer 7

1. if a professional is highly trained & tries hard enough he/she will not make errors
2. if we try hard enough we will not make any errors.
3. if we punish people when they make errors they will make fewer of them
4. Human beings carrying out complex and risky procedures in our time pressurized healthcare organisations will make errors.

95% of errors that cause harm involve conscientious, competent individuals trying to achieve a desired outcome (only 5% of harm is caused by incompetence)

Question 8

Person v System approach

1. What is the person approach?
2. What is the system approach?
3. What is a ‘Just Culture’

Answer 8

1. Focuses on the unsafe act, ‘name and shame’ individuals.
2. Errors seen as consequence of unsafe systems; aim is to build defences and safeguards - robust systems that protect patients from harm.
3. Balanced approach, clarification of accountability.

Question 9

The National Patient Safety Agency has developed a hierarchy to help prevent errors

What is this hierarchy?

Answer 9

• Design out the potential for harm
• Make incorrect actions correct
• Make wrong actions more difficult
• Make it easier to discover errors

Question 10

Structured Systems

1. What are examples of low-tech systems?
2. What are examples of high-tech systems?

Answer 10

1. written guidelines, protocols, standardised forms for completion, reminders, visual prompts
2. infusion pumps, bar coding, computerised medication systems

Question 11

Designing Reliable Care Systems

Give examples of how the following can be beneficial

1. Prevent failure
2. Identify and Mitigate Failure
3. Seek to reduce the mistake opportunities
4. Redesign the process

Answer 11

1. basic standardisation, memory aids such as checklists, feedback regarding compliance with standards, awareness-raising and training.
2. (Second tier strategies) focus on “catching” or identifying instances when the standardised approach is not used
3. utilising more sophisticated failure prevention; often referred to as “error-proofing”
4. based on the critical failures identified - Even with the first two levels in place, what weaknesses in the design of the standardised processes are leading to or might lead to failure?