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WELCOME……. Please take a moment to write down all the little (or not so little!) mistakes you have made in the last 2 days when you were NOT at work. TYPES OF ERRORS. Slips, lapses, fumbles Attention lapse, unintended action Rule-based mistakes

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welcome

WELCOME……...

Please take a moment to write down all the little (or not so little!) mistakes you have made in the last 2 days when you were NOT at work

types of errors
TYPES OF ERRORS
  • Slips, lapses, fumbles
    • Attention lapse, unintended action
  • Rule-based mistakes
    • Think you know what you're doing, but fail to notice contra-indications, apply a bad 'rule' or fail to apply a good 'rule'
  • Knowledge based mistakes
    • Novel situations
    • Not sure or clearly don’t know what you're doing
  • Violations
    • Deliberate rule breaking
human factors in health care
HUMAN FACTORS IN HEALTH CARE
  • Error is the downside of having a brain
    • limited memory capacity
    • limited processing capacity
    • confounding factors - stress, fatigue, culture
  • Medical environment
    • stress - loss of situational awareness
    • tendency to defend perception
    • doctors trained to be flawless
    • lack of trust in others
case 1 liver biopsy
Case 1Liver Biopsy
  • 10 year old boy with hepatomegaly ?hepatitis
  • Booked for liver biopsy (with prolonged APTT)
  • Ordered on medication chart:
    • 10mg IV vitamin K -
    • 2 units FFP -
case 1 liver biopsy7
Case 1Liver Biopsy
  • 1100h liver biopsy undertaken
  • Ward 1400h post biopsy
    • BP 49/33, PR 140/min
  • Resuscitation fluid ordered
      • 1415h FFP
      • 1445h FFP
      • 1530h blood 200ml/hr
      • 1600h 0.9% NaCl
      • 1630h blood 200ml/hr
case 1 liver biopsy8
Case 1Liver Biopsy
  • 1810h Code Blue (pre MET)
  • Pale, barely conscious
  • Returned to Operating theatre
  • 2 litres of clotted blood & ascites in abdomen
slide9

Some holes due to active failures

Liver biopsy

FFP ward

FFP OT

Clinical status

Resuscitation

Culture

Processes

Training

Communication

Shock

OT

Training

Other holes due to latent conditions

Successive layers of defence

James Reason - Human Error 1990

case 2 pyloric stenosis
Case 2 Pyloric stenosis
  • 4 wk old baby
  • Pyloric stenosis diagnosed in ED
  • Intravenous fluid requested by surgeon commencing with a 10mL/kg bolus over ½ hr (infant’s weight 4kg)
  • Bolus of fluid written by staff A as

“N Saline 400 ml IV over 1/2 hour”

case 2 pyloric stenosis11
Case 2 Pyloric stenosis
  • Checked and signed by staff B & C
  • IV fluid at 800 ml/hr on IV pump (=400ml over 1/2 hr)
  • Child went to the ward
  • Staff D - “??? IV fluid rate” & pushed Stop button and called the Surgeon
  • IV fluid order corrected, child OK
slide12

Pyloric stenosis

IV fluid

Some holes due to active failures

Incorrect order

Order checked

Pump programmed

Ward handover

Medication

ordering

Processes

Equipment purchasing

Culture

Other holes due to latent conditions

Successive layers of defence

James Reason - Human Error 1990

types of errors13
TYPES OF ERRORS
  • Slips, lapses, fumbles - OBSTACLES
    • Attention lapse, unintended action
  • Rule-based mistakes –
    • Think you know what you're doing, but fail to notice contra-indications, apply a bad 'rule' or fail to apply a good 'rule'
  • Knowledge based mistakes
    • Novel situations
    • Not sure or clearly don’t know what you're doing
  • Violations
    • Deliberate rule breaking
system obstacles
SYSTEM OBSTACLES
  • Electronic ordering
  • Standardised pumps throughout RCH
  • Programmed intravenous pumps
  • Standardised Handover practices
  • Time Out Check
  • Parents
prescribing obstacles
Prescribing obstacles……
  • Prescribing drugs – check dosage guides
  • Prescribing IV fluids – follow the guideline
  • Know common drugs involved in error and double check!
  • Use patient’s current weight
  • Check drugs given in other departments
  • Write legibly.
types of errors16
TYPES OF ERRORS
  • Slips, lapses, fumbles - OBSTACLES
    • Attention lapse, unintended action
  • Rule-based mistakes –
    • Think you know what you're doing, but fail to notice contra-indications, apply a bad 'rule' or fail to apply a good 'rule'
  • Knowledge based mistakes
    • Novel situations
    • Not sure or clearly don’t know what you're doing
  • Violations
    • Deliberate rule breaking