W3 Patient safety

Question 1

Bristol heart scandal:

Answer 1

• Babies die at high rates after cardiac
  surgery
• Staff shortage
• Lack of leadership
• An ‘old boys’’ culture
• Lax approach to safety
• Secrecy about performance

Question 2

What is the definition of patient safety?

Answer 2

• Patient safety is the avoidance of unintended or unexpected harm to
  people during the provision of health care.
• Healthcare professionals should work together to minimise patient safety
  incidents and drive improvements in safety and quality.
• Patients should be treated in a safe environment and protected from avoidable harm.

Question 3

To Err is Human: Building a Safer Health System

Answer 3

More people die annually from medication errors than from workplace injuries

• To Err Is Human breaks the silence that has surrounded medical errors and their
  consequence–but not by pointing fingers at caring health care professionals who make honest mistakes.
• To Err Is Human asserts that the problem is not bad people in health care–it is that
  good people are working in bad systems that need to be made safer.

Question 4

To Err is human
What are the main points discussed in this report (7)
(errors, reporting, awareness)

Answer 4

1. Prevalence of medical errors
2. Human errors
3. Systemic causes
4. Accountability and reporting
5. Development of the National Patient
   safety Agency
6. Continuous improvement
7. Patient awareness

Question 5

What is the Swiss cheese method?

Question 6

What are the six safety competencies included in the ‘safety competencies framework’?

Answer 6

1. Recognising the importance of ongoing
   collaboration and the commitment to
   advocate for change.
2. Demonstrate capabilities and
   competencies that are essential to
   efficient, effective and safe collaborative
   practice.
3. Effective communication benefits both
   patients and healthcare providers, builds
   trust and is a precondition of obtaining
   patient consent.
4. Collect and monitor performance data to
   assess risk and improve outcomes.
5. Optimising the human and environmental
   factors that support the achievement of
   best human performance.
6. Open, honest and empathetic disclosure
   and appropriate apologies by healthcare
   providers benefit everyone: patients and
   families, healthcare providers and their
   organisations.

Question 7

Incident Reporting:
List the five steps of the ‘patient safety incident reporting’.

Answer 7

1. Record- record all errors and near misses. Involve the whole team
2. Learn- Identify and investigate cause of errors. Use them as a learning opportunity
3. Share- Discuss with others and promote learning
4. Act- Make changes to Practice
5. Review- Review changes to Practice