20 th and 22 nd september 2011
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RISC Patient Safety. 20 th and 22 nd September 2011. Acknowledgements. Facilitators Adam Figgins Adrian Hayes Rosalind Pool Siobhan Reilly Poppy Roberts Chris Roughley Tommy Salter Jessica Scott Sarah Watson Rebecca Woodside. Dr Vinod Patel, WMS

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20 th and 22 nd September 2011

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20 th and 22 nd september 2011

RISC

Patient Safety

20th and 22nd September 2011


Acknowledgements

Acknowledgements

  • Facilitators

    • Adam Figgins

    • Adrian Hayes

    • Rosalind Pool

    • Siobhan Reilly

    • Poppy Roberts

    • Chris Roughley

    • Tommy Salter

    • Jessica Scott

    • Sarah Watson

    • Rebecca Woodside

  • Dr Vinod Patel, WMS

  • Institute for Applied Teaching and Learning


20 th and 22 nd september 2011

Plan

  • 7:00 – 7:30 Introduction

  • 7:30 – 7:45Station 1

  • 7:45 – 8:00Station 2

  • 8:00 – 8:30Refreshments

  • 8:30 – 8:45Station 3

  • 8:45 – 9:00Station 4


Evaluation

Evaluation

  • Consent Form

  • Questionnaires

    • Before and After

  • Interviews

  • Follow-up

  • Please complete Before questionnaires now


What is patient safety

What is Patient Safety?

  • The freedom from accidental injury due to medical care or from medical error

    (Institute of Medicine 2000)

  • ‘doing the right thing to the right person at the right time, getting it right first time’

    (Ambrose, 2009)


Hospitals are hazardous

Hospitals are Hazardous

“If you fly on a plane, you have a one in 10m chance of being killed.

If you go into hospital, you have a one in 300 chance – and not from the illness you went in with.”

Richard Branson


Hospitals are hazardous1

Hospitals are Hazardous

Amalberti et al, 2005


Everyone makes mistakes

Everyone Makes Mistakes

  • Why?

    • Heavy workload

    • Fatigue

    • Stress

    • Shift work

    • Reliance on memory

    • Reliance on vigilance

    • Noise

    • Distractions

    • Unnatural workflow

Watson, 2010


Swiss cheese model

Swiss Cheese Model

Reason, 2000


Medical error

Medical Error


Medical error1

Medical Error


Medical error2

Medical Error


Medical error3

Medical Error

  • Just a Routine Operation


Patient safety solutions

Patient Safety Solutions


Patient safety solutions1

Patient Safety Solutions

  • Protocols and checklists

  • Constraints

  • Forcing functions

  • Encouraging function

  • Discouraging functions

  • Leadership and Culture


Medical curriculum

Medical Curriculum

  • Recommendations

    • BMA

    • GMC

    • WHO

  • Little formal teaching

    Walton et al, 2010

  • RISC initiative


Chips stations

CHiPS Stations

  • How to prepare for surgery

  • How to hand over a patient

  • How to recognise an ill patient, and what to do about it

  • How to spot an unsafe clinical event, and what to do about it


20 th and 22 nd september 2011

RISC

Patient Safety

  • 3rd and 4th year students

  • 3 grants

  • 1 publication (in press)

  • 17 projects

    • Handover

    • ED Admissions

    • Sepsis

    • Medication Error Audits

    • Surgical Safety Checklist

    • iPhone App

    • Uniforms for Medical Students

Get Involved!


Conclusion

Conclusion

  • Patient safety is important (and interesting)

  • Medical students can contribute


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