Week 5 - Patient safety

Question 1

Patient safety

Answer 1

-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 2

To Err is human: building a safer health system

Answer 2

-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 3

To Err is human: building a safer health system -> steps for improvement

Answer 3

The report emphasises the following:
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 4

Patient safety umbrella

Answer 4

Clinical human factors and patient safety are closely interlinked:
Patient safety:
-Teamwork
-Safety culture
-Communication
-Safety, risk and quality
-Clinical human factors and system thinking
-Patient safety incident reporting and investigation centred

Question 5

Human error

Answer 5

-Errors in care can be caused by human error and equipment failures
Human error can happen for many reasons like;
-Wellbeing
-Cognitive error
-Over/ underestimating personal ability
-Poor situational analysis
Other factors that can cause error include;
-Environment
-Workload
-Organisational culture

Question 6

The NPSA 7 steps to patient safety

Answer 6

1)Build a safety culture
2)Lead and support your staff
3)Integrate your risk management activity
4)Promote reporting
5)Involve and communicate with
patients and the public
6)Learn and share safety lessons
7)Implement solutions to prevent harm

Question 7

Patient safety – 7 rights

Answer 7

1)Right patient
2)Right drug
3)Right dose
4)Right route
5)Right time
6)Right information
7)Right documentation

Question 8

LASA (look alike, sound alike)

Answer 8

Dispensing errors can cause serious harm to patients - always triple check product name and strength!!!

Question 9

Incident reporting

Answer 9

RECORD -> record errors and near misses, involve the whole team
LEARN -> identify and investigate the cause of errors - use them as a learning opportunity
SHARE -> discuss with others and promote learning
ACT -> make changes to practice
REVIEW -> review changes to practice

Question 10

Duty of candour

Answer 10

-Being open and honest when things go wrong
-Saying sorry

Question 11

Patient safety professional standards

Answer 11

-Evaluate
-Reflect
-Be open and honest
-Review
-Record and report
-Act
-Share learning