slide1
Download
Skip this Video
Download Presentation
Objectives

Loading in 2 Seconds...

play fullscreen
1 / 40

Objectives - PowerPoint PPT Presentation


  • 127 Views
  • Uploaded on

Objectives. By the end of this session you will be able to: explain the term ‘error’ explain why errors are made describe individual strategies to reduce the frequency of errors. Patient Safety and the Australian Curriculum Framework for Junior Doctors. Adverse events in health.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Objectives' - MikeCarlo


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
objectives
Objectives

By the end of this session you will be able to:

  • explain the term ‘error’
  • explain why errors are made
  • describe individual strategies to reduce the frequency of errors
adverse events in health
Adverse events in health
  • Contribute to about 18,000 deaths per year in Australia

(approximately 10 times the road toll)

  • Occur in up to 16% of all hospital admissions

Quality in Australian Healthcare Study

(Wilson et al. MJA 1995)

Ice Breaker

Click to view video

have you made any silly mistakes recently
Have you made anysilly mistakes recently?

What happened?.......

What were the consequences?.....

what is an error
What is an “error”?

“Doing the wrong thing when meaning to do the right thing” (Runciman)

  • A more formal definition is: (Reason)
    • “planned sequences of mental or physical activities that fail to achieve their intended outcomes, when these failures cannot be attributed to the intervention of some chance agency”
error and outcome
Error and outcome
  • Error and outcome are not inextricably linked
    • Harm can befall a patient in the form of a complication of care without an error having occurred1
    • Many errors occur that have no consequence for the patient either due to a timely intervention (eg clinical pharmacist intercepting wrong dose) or due to chance
  • (QAHCS – 75% of incidents had an element of ‘human error’)
basic principles about error
Basic principles about error
  • We all make errors all the time
  • The same error (even minor ones) can have different consequences
  • Errors are not bad or morally wrong – BUT

Healthcare workers expect perfection of themselves (and colleagues)

AND

We often ascribe blame to individual without looking at wider circumstances

Adapted from Queensland Health Human Error

and Patient Safety Training (HEAPS)

outcome definitions
Outcome Definitions
  • Clinical incident
  • Near miss (or ‘no-harm incidents’)
  • Adverse event (or ‘harm incidents’)
  • Harm
  • Sentinel event
  • Clinical incidents = Near misses (90%) + Adverse events (10%)
types of errors
Types of errors
  • Slips - I put salt in my tea not sugar…
  • Lapses - I was interrupted and forgot to take the document out of the copier…
    • Usually repetitive actions
  • Mistakes - I thought the problem was hypovolaemia but it was cardiogenic shock…
    • Wrong plan or action
slide14

Courtesy P. Croskerry

Courtesy P. Croskerry

slide16

Courtesy P. Croskerry

Courtesy P. Croskerry

why do we misinterpret things sometimes
Why do we misinterpret things sometimes?

Because the human brain is so….

  • Good at finding shortcuts (fast)
  • Good at filtering information
  • Good at making sense of things
  • Usually this is a good thing, sometimes it fools us
  • Error is the “downside to having a brain”!
the environment can set us up to make errors
The environment can “set us up” to make errors
  • look-alike and sound-alike pharmaceuticals
  • equipment design
    • e.g. defibrillators
  • user interfaces
    • e.g. infusion pumps
situations leading to error the three bucket model
Situations leading to error:The “Three Bucket” model

Distraction

Inadequate handover

Production pressure

Equipment failure

Poor knowledge

Fatigue

Little experience

Feeling ill

Variation from “normal”

Omission errors

Unfamiliar equipment

Reason 2004

video
VIDEO
  • Watch this video of a “typical day” in the emergency department
  • How did the mistakes come about?
  • Were they inevitable or avoidable?

Faultlines

part 1

Click to view video.

Do not interrupt video once started.

Let video run through its entirety.

video26
VIDEO
  • What circumstances have you noticed so far that may contribute to an error?
  • What strategies is the junior doctor using to minimise these factors?

Faultlines

part 2

Click to view video.

Do not interrupt video once started.

Let video run through its entirety.

what were the contributing factors in this case
What were the contributing factors in this case?

Variation from “normal”

Omission errors

Unfamiliar equipment

Poor knowledge

Fatigue

Little experience

Feeling ill

Distraction

Inadequate handover

Production pressure

Equipment failure

Reason 2004

performance shaping factors
Performance-shaping factors
  • I Illness
  • M Medication
    • prescription, alcohol & others
  • S Stress
  • A Alcohol
  • F Fatigue
  • E Eating

Am I safe to work today?

stress and performance
Stress and Performance

Area of “Optimum” Stress

Performance Level

High Stress Anxiety, Panic

Low Stress Boredom

Stress Level

The Relationship Between Stress and Performance

don t forget
Don’t forget ….

If you’re

  • H ungry
  • A ngry
  • L ate

or

  • T ired …..

H

A

L

T

personal error reduction strategies
Personal error reduction strategies
  • Know yourself
    • eat well, sleep well,
    • look after yourself …
  • Know your environment
  • Know your task
  • Preparation & planning
    • “What if …?”
  • Build ‘checks’ into your routine
  • Speak up if you don’t know!
systems problems
Systems problems
  • May be inadequate staffing, too busy etc.
  • Design of equipment makes it difficult to do the right thing
  • Difficulties working as a team
  • No or patchy orientation
  • Often no clear accountability
  • No ‘standard operating procedures’
  • Culture which allows unacceptable behaviours
communication and teamwork
Communication and Teamwork
  • Be precise with your communication
    • Use clinical terms not social speak
  • Practice effective handovers
  • Encourage ‘read-back’ of important information
    • eg. Confirming instructions or drug doses if given over the telephone
  • Remember to have structured briefings (‘Time outs’) before procedures
  • Have a structure and plan what you need to say…
mental preparedness
Mental preparedness
  • Assume that errors can and will occur
  • Identify those circumstances most likely to lead to error
  • Have contingencies in place to cope with problems, interruptions and distractions – discuss them aloud with your team
  • Mentally rehearse complex

procedures

Getting the balance right

technology
Technology
  • New technology doesn’t solve

the problems

  • New technology makes new problems or can even make

old problems even worse!

slide39

New technology makes new errors…

Errors in counting drops per minute

Risk of unnoticed occlusion

Mis-programming (eg. 10-fold or decimal point errors)

Risks of malfunction, battery failure, ignoring alarms etc.

OR

OR

summary
Summary
  • Making errors is an inevitable part of the human condition - it’s how we’re built!
  • Be aware of yourself, the context and the task – ask:
    • “what are the risks?”
    • “what are the ways to minimise the risk?”
  • Communicate effectively and use your team – they are your eyes and ears
ad