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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.

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Presentation Transcript
Objectives l.jpg
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



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Adverse events in health Junior Doctors

  • 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


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Have you made any Junior Doctorssilly mistakes recently?

What happened?.......

What were the consequences?.....


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What is an “error” Junior Doctors?

“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”


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Error and outcome Junior Doctors

  • 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’)


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Basic principles about error Junior Doctors

  • 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)



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Outcome Definitions Junior Doctors

  • Clinical incident

  • Near miss (or ‘no-harm incidents’)

  • Adverse event (or ‘harm incidents’)

  • Harm

  • Sentinel event

  • Clinical incidents = Near misses (90%) + Adverse events (10%)


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Types of errors Junior Doctors

Reason


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Types of errors Junior Doctors

  • 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


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Courtesy P. Croskerry Junior Doctors

Courtesy P. Croskerry


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Courtesy P. Croskerry Junior Doctors


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Courtesy P. Croskerry Junior Doctors

Courtesy P. Croskerry


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Why do we Junior Doctorsmisinterpret 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”!


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The environment can “set us up” to make errors Junior Doctors

  • look-alike and sound-alike pharmaceuticals

  • equipment design

    • e.g. defibrillators

  • user interfaces

    • e.g. infusion pumps


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Situations leading to error: Junior DoctorsThe “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


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VIDEO Junior Doctors

  • 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.


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VIDEO Junior Doctors

  • 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.


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What were the contributing factors in this case? Junior Doctors

Variation from “normal”

Omission errors

Unfamiliar equipment

Poor knowledge

Fatigue

Little experience

Feeling ill

Distraction

Inadequate handover

Production pressure

Equipment failure

Reason 2004


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Performance-shaping factors Junior Doctors

  • I Illness

  • M Medication

    • prescription, alcohol & others

  • S Stress

  • A Alcohol

  • F Fatigue

  • E Eating

    Am I safe to work today?


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Stress and Performance Junior Doctors

Area of “Optimum” Stress

Performance Level

High Stress Anxiety, Panic

Low Stress Boredom

Stress Level

The Relationship Between Stress and Performance


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Stress and Performance Junior Doctors


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Don’t forget …. Junior Doctors

If you’re

  • H ungry

  • A ngry

  • L ate

    or

  • T ired …..

H

A

L

T


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Personal error reduction strategies Junior Doctors

  • 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!


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Systems problems Junior Doctors

  • 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


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Communication and Teamwork Junior Doctors

  • 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…


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Education package available from PMCV and Junior Doctors

Southern Health


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Mental preparedness Junior Doctors

  • 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


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Technology Junior Doctors

  • New technology doesn’t solve

    the problems

  • New technology makes new problems or can even make

    old problems even worse!


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New technology makes new errors… Junior Doctors

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


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Summary Junior Doctors

  • 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