Surgical errors

Question 1

what is an error?

Answer 1

an unintended act or an act that does not achieve its intended outcome

Question 2

what is an adverse event?

Answer 2

injury caused by medical management rather than the underlying condition

Question 3

what is a risk?

Answer 3

likelihood of harm from a potential hazard

Question 4

what is a hazard?

Answer 4

potential source of harm

Question 5

what is difference between active and latent errors?

Answer 5

active: occurs at time of event
latent: occurs upstream of error (eg merging of patient records in wrong way months before treatment)

Question 6

what is difference between slips and lapses?

both executive errors

Answer 6

slips: attentional failure when carrying out familiar task
lapse: memory failure in complex tasks

Question 7

what is the swiss cheese model?

Answer 7

complex system with many layers, but holes in each layer can align and an error can pass all the way through.

Question 8

what are the key phases of WHO surgical safety checklist?

Answer 8

3 key phases:

1. sign in before induction (identity, procedure, site, consent, marking, monitoring)
2. timeout before incision (introductions, person, procedure, site, critical events, antibiotics, essential imaging)
3. sign out before wound closure (procedure, instrument, swab count, specimens, equipment issues, recovery)

Question 9

examples of areas from which teamwork errors arise?

Answer 9

communication
planning
situational awareness
leadership

Question 10

what is statuatory duty of candour?

Answer 10

Health and Social Care Act 2008/2014

openness and transparency for all incidents that could cause death, severe harm, moderate harm, and prolonged psychological harm.

Question 11

what is root cause analysis

Answer 11

structured, thorough investigation of a patient safety incident to determine underlying causes and identify learning points

Question 12

what are 7 stages of NPSA root cause analysis?

Answer 12

Getting started
Gathering and mapping information
Identifying care and service delivery problems
Analysing the information
Generating recommendations and solutions
Implementing solutions
Writing the report

Question 13

what are never events?

Answer 13

serious incident that is:

• wholly preventable
• potential to cause serious harm/death
• has occurred in the past

Question 14

what are benefits of patient complaints?

Answer 14

assist in maintaining standards
reduce litigation
maintains trust
encourages reflection
protects the public