Systems Approach to Patient Safety and Root Cause Analysis Flashcards
How is healthcare a complex sociotechnical system?
Culture Policies Goals Legal context Financial Context
What are the four sub-categories of error?
Slips (commission): Failure of attention
Lapses (omission): Failure of memory
Mistakes: Rule based or knowledge based
Violations.
What is the common reason for an adverse event?
A systems failure -not normally a single person
What is an adverse event?
Patient safety incident:
An unintended unexpected incident which could have or did, lead to harm for one or more patients receiving healthcare.
Never event:
Serious, largely preventable should not occur if preventative measures in place.
What is the difference between a patient safety incident and a never event?
- Seriousness
- Preventability
- Measures in Place
What are patient safety incidents?
Events in healthcare where the potential for learning is so great or the consequences to patients, families and carers. staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response.
What things class as a Patient Safety Incident?
Acts and/or omissions that result in:
Unexpected / avoidable deaths
Unexpected / avoidable injury that leads or could have lead to harm
Never events
An / multiple incidents that prevents or threatens to prevent an organisation’s ability to continue delivering an acceptable quality of care/
What is the key recommendations of” an organisation with a memory”?
National reporting system
Improving in the quality of investigation of Adverse Events
Systems approach to hazard identification and prevention
What is a system?
Set of elements (people, processes, information, organisations, software, hardware, ect.) that when the combined qualities that are not present in any of the elements themselves
What is root cause analysis?
Structured approach to the retrospective investigation of adverse events (usually PSIs) in healthcare focusing on the identification of underlying facts (latent) causing the problems(s).
It aims to answer:
What happened?
Why did it happen?
What cane done to prevent it from happening again?
What techniques can be used?
Fishbone diagram
5 Whys
Timelines
What is Ishikawa’s Fishbone Diagram?
A visualization tool for categorizing the potential causes of a problem in order to identify its root causes.
What is the most difficult part of a fishbone diagram?
Defining the problem.
What is the five why’s?
5 Whys is a technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question “Why?”. Each answer forms the basis of the next question.
What is timeline mapping?
Go through all the events that took place and compare it to the events that should’ve happened.
