week 3: Flashcards
What are the 4 types of common healthcare risks?
1- treatment
2- diagnostics
3- preventive
4- others ( failure of communication, equipment failure, other systems)
what are the 6 domains of quality care? STEEEP
safe
timely
efficient
equity
effective
patient centered
Most Common Root Causes of Medical Errors 8
- Communication problems
- Inadequate information flow
- Human errors
- Patient-related issues
- Organizational transfer of knowledge/training
- Staffing patterns/work flow
- Technical failures
- Inadequate policies and procedures
Swiss Cheese Model (By James Reason)
Defences Against Hazards in Systems
* Good Documentation
* Clear Communication
* Regular Training
* Well Thought Out Operating Procedures
* Effective Supervision
* Thorough Inspection
21
Unfortunately, the defences in the real world have ‘holes’ in
them (like the swiss cheese) which allow the hazards to pass
through:
× Incomplete documentation
× Inadequate shift handover
× Lack of clear clinical guidelines
× No supervision for new staff
Hazard
Hazard
Defences Against Hazards in Systems 6
Good Documentation
* Clear Communication
* Regular Training
* Well Thought Out Operating Procedures
* Effective Supervision
* Thorough Inspection
Active failures
encompass the unsafe acts that can be
directly linked to an accident involving frontline staff (e.g.
failure to do two patient identifiers)
What Contribute to the Risks of Medical Error?
- All humans make errors – “To Err is Human”
- Most of medicine is complex and uncertain –
variations in healthcare are increasing - Most errors result from “defective system” (e.g.
inadequate training, long hours, ampoules that look
the same, lack of checks, etc) - Healthcare has not tried to make itself safe
Accountability for Our Behavioural Choices
Just Culture
Reckless
Behaviour
Intentional Risk-Taking
Manage through:
* Remedial action
* Disciplinary action
Punish
At-Risk Behaviour
Unintentional Risk-Taking
Manage through:
* Removing incentives
for at-risk behaviors
* Creating incentives for
healthy behaviors
* Increasing situational
awareness
Coach
Human Error
Product of our current system design
Manage through changes
in:
* Processes
* Procedures
* Training
* Design
* Environment
Console
4Fundamental Steps of Risk Management
- Risk Identification
- Risk Analysis
- Risk Mitigation / Control
- Risk Monitoring / Review
Risk Identification
Identify potential risk factors from incident /
process reviews
1. Root Cause Analysis (RCA)
* Retrospective review of past incidences to establish root
causes for problems and solutions to minimize the risk of
reoccurrences of similar incidences
➢ Retrospective analysis (after a serious error/near miss)
➢ Chronology of events (leading to the incident)
➢ Focuses primarily on systems and processes
- Healthcare Failure Mode & Effects Analysis (HFMEA)
* Proactively look at the many steps in a process, especially
those which are new or high risks
* Flow chart the process, predict where risks or “failure
modes” exist and redesign process to eliminate those risks
. Risk Analysis
Analyze to determine the risk levels:
* Events, patterns and frequencies of events and system
defects that contribute to occurrence – from hospital
incident reports & SRE reviews
* Traits of patients susceptible to high risk events are
developed
* Environmental elements contributing to high risks are
categorized
Determining Risks Priority
Risk Priority Number =
(RPN)
Likelihood of
occurrence of
harm
X Severity of harm
isks with the following conditions
will be considered as significant:
1. RPN > or = 9
2. Severity or occurrence equal or
greater than 4, and without any
current control
3. Legal implications
4. Affecting reputation of institution
. Risk Mitigation / Control
Formulate intervention strategies
* Solicit suggestions and observations from a variety of
sources
* Utilize these to formulate alternative approaches to
mitigate identified risks
* Engage end-users from the beginning in planning
strategies and action plans
Strategies to Mitigate Risks
- Risk Avoidance / Removal
* Remove the risk by doing things differently where it is feasible to do
so (e.g. removal of concentrated KCl from all patient areas) - Risk Reduction / Control
* The development and implementation of policies, standards,
procedures and physical changes to reduce risks of adverse events
(e.g. performing “Time-Out”) - Risk Transfer
* Shifting responsibility or burden for loss to another party through
legislation, contract, insurance or other means (e.g. third party
vendor for housekeeping service) - Risk Acceptance
* Tolerate the risk − perhaps because nothing can be done at a
reasonable cost to mitigate it or the likelihood and impact of the
risk occurring are at an acceptable level (e.g. employment of foreign
healthcare staff
risk against data to assess effectiveness of the actions
taken
✓ Review of incident (IRS) and complaint cases
✓ Review of organisational policies, strategies and processes
✓ Through quality indicators
✓ Through performance indicators
✓ Conduct Audits to check compliance
3. Yearly Review of Risks Register to Evaluate Impact
4. Risk Monitoring / Review1. Communicate high alert risks to stakeholders
2. Follow up on risk treatment options and analysis of
risk against data to assess effectiveness of the actions
taken
✓ Review of incident (IRS) and complaint cases
✓ Review of organisational policies, strategies and processes
✓ Through quality indicators
✓ Through performance indicators
✓ Conduct Audits to check compliance
3. Yearly Review of Risks Register to Evaluate Impact
4.
