Viva - Critical Incident Flashcards
What is a patient safety incident
An incident that is
Unexpected
Unintended
Undesired
Associated with actual or potential harm
Why are ICU patients at risk of safety incidents
Highly invasive treatments with potential for complication
Frequent iv drugs/fluids — margin for error
Intensive interventions
Lack capacity/autonomy, can’t communicate an issue as sedated
Lack physiological reserve
Stages of getting a medication. When do these errors happen
Prescription Transcription Preparation Dispense Admin
Administration is where most errors happen
Difference between medical errors and adverse drug events ADE
Med errors - any mistake in prescription/prep or admin of a drug
Doesn’t necessarily cause harm
ADE - medication error where harm occurs
Why are medication errors more common on ICU
Patient factors - severe of illness and age ..more drugs
Long hospital stay
Sedation/lack of capacity
Changes in pharmacodynamic
Medication - increased number and routes, use of pumps, estimated weight
Environment - turnover of patients and staff, stress, conditions, emergency’s
Comma problems/poor IT
How can we reduce medication errors
Alter environment - reduce working errors
Supervise trainees
Stop distractions/interruptions
Optimise medication process - standardise meds, computerised systems
Prevent oversights - staffing, use of pharmacist, education
What is a Never Event
Serious incidents that are WHOLLY PREVENTABLE
Because - guidance or safety recommendations have such strong protective barriers
Available at NATIONAL LEVEL, and
Implemented to ALL healthcare providers
Never events list
Surgical - wrong site, wrong implant, retained foreign object
Mental health - no collapsible curtain rail
Meds - Wrong potassium solution choice
Wrong route of admin
Insulin overdose
Methotrexate overdose in non Ca patients
Mis-selection of high strength midaz for concours sedation
General - fall out of windows, chest/neck stuck in bed rails
Transfusion reactions
Scalding
Misplaced NG tube
NG tube procedure
1) DO NOT PUT ANYTHING DOWN UNTIL CONFIRMED
2) 1st line pH. 1-5.5
CE marked indicators. Needs to clearly differentiate 5 from 6
Clearly document
3) 2nd line CXR
When no aspirate or pH paper unclear
4) documenting length and checking regularly.
After an NG CXR, what to document
Who authorised CXR
Who confirmed position and are they competent
Confirm this is the most current x ray
Rationale for needing CXR
What to be aware of with NG tubes in ITU
We often alter the pH, and they are at risk of misplacement, so get CXR if in doubt
How to minimise a Never event
Two person drug/blood checks Use of barcodes Checklists/LOCSIP/NATSIP Debrief Process standardisation
Team training in command/human factors
E learning
Open comms and learn from mistakes
What to do if involved in a Never Event
Failure to report in UNACCEPTABLE - represents cultural failings
1) patient safety is number 1
Ensure they are safe - get the complications treated
2) Inform responsible consultant and departmental lead
3) inform patient/family ASAP, document the discussion
4) Incident report
5) Report to relevant commissioner as Serious Incident Framework
6) Investigate - RCA
