Types of error Flashcards
What is sloth error?
being lazy, not bothering to check results/ information for accuracy. There is incomplete evaluation
How can sloth error be improved?
paying attention to detail and checking information
What are other types of error?
● Fixation ● Communication breakdown ● Playing odds ● Bravado ● Ignorance ● Miss-triage ● Lack of skill e.g. a med student doing a hysterectomy ● System error
Why does error happen?
● human error ● misconduct ● judgement failure - taking too great a risk ● neglect ● poor performance
what is bravado?
show of courage, especially when unnecessary and dangerous
What are never events?
Events that should NEVER happen?
Give some examples of never events
Wrong site surgery
Wrong route of administration
Wrong prescribing of K+ containing solution
Overdose of insulin
What is the Swiss cheese model of adverse events?
illustrates that, although many layers of defense lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the accident to occur.
What is the Bolam standard?
rules in favour of the general medical opinions around acceptability
Not negligent if acting in a way that is in accordance with accepted practice and
other practitioners mostly agree
What are the criticisms of the Bolam standard?
overly protective of clinical staff
When is Bolam used?
each medical interaction surrounding disclosure and omission of risks in informed consent
When does negligence occur? give the four steps
○ There was a duty of care ○ This was breached ○ A patient came to harm ○ The harm was due to the breach in the duty of care
What are the criteria for negligence?
1) There was a duty of care between the doctor / nurse
and the patient
2) The act of omission of the doctor or nurse breached
this duty of care
What is the Bolitho Caveat
A JUDGE CAN DISAGREE WITH A PANEL OF MEDICS IF THEY THINK IT IS UNACCEPTABLE
Just read this lol -> A doctor could be liable for negligence in respect of diagnosis and treatment despite a body of professional opinion sanctioning his conduct where it had not been demonstrated to the judge’s satisfaction that the body of opinion relied on was reasonable or responsible
hehe
