2. ?????? ??? (????) ??? ?????? ?????? ?????? ???? ?????? ?????????? ? ????? ????? ?????? ????? ?????? ????? ? ????? ? ?????

3. ?????? ???? (???) ?????   ??????? ?? ?? ?????? ??? ?? ?? ??? ????

7. ???? ?? ?????? ? ????? ????? ???? This slide compares HC with other potentially hazardous activities and industries. It is exceedingly dangerous: comparable to mountain climbing in the risk of a fatality, and exceeding road traffic accidents in the number of people killed each year.This slide compares HC with other potentially hazardous activities and industries. It is exceedingly dangerous: comparable to mountain climbing in the risk of a fatality, and exceeding road traffic accidents in the number of people killed each year.

11. ????? ????? ????? 2-4 ???? ?? ?? ???? ????  Brenan (2000) ???? 0.1% : 1 ???? ?? ???????? ?????? ?? ????? ?? ??? ???? ?? ???? ?? ??????? ?? ??????? ??????16?000 ???? ?? ??? ?? ?? ????22?000 ?? ?????? ?? ???? ????? ???? ????20?000 ????? ???? ?????? ?? ???500 ??? ????? ?????? ?? ?? ???? ?????? 50 ????? ?? ????? ???? ?? ??? ?? 20-40 ??? ??? ????? ???? 2-4 ???? ?? ???? ?? ??? At this slide, go back and remind them that Brennan found 2-4% rate of medical errors. Comment that 2-4% may sound trivial, but then have them consider the numbers on this slide, which are for a 0.1% error rate! Then have them consider the math of what they would translate to at 2-4%!At this slide, go back and remind them that Brennan found 2-4% rate of medical errors. Comment that 2-4% may sound trivial, but then have them consider the numbers on this slide, which are for a 0.1% error rate! Then have them consider the math of what they would translate to at 2-4%!

12. 16-10 ???? ?? ??????? ????? ?? ????????? ???? ??? ?? ????? ???????? ?? ????. ???? ?? ??? ????? ???? ?????? ? ??????? ?????. ?? ??? ??? ? ?????? ????? 3 ??? ?? ????? ?? ?? ??? ????? ??? ?? ??? ????? ?? ????? ?? ??? ????? ??? ??? (??? ???? ??????? ????)

14. ???? ???? ?? ?? ??? ?? ???? ??????? ?????? ?? ??????? ?? ?????? ?? ????????? ???? ????? ????? ???????????? ???? ????? ? ????? ???? ?? ????? ????? ????????. ???? ????? ?????????? ???????- ?????? ?????? ????? ???? ??????? ???? ????? ?????? ?? ???? ?????? ?????? ???? ??? ??????? ????? ?????? ? ?????? ????? ????? ????? ? ???? ????.

15. ?????? ?????? - ?? ????? ????? ?? ?????? ?? ?? ????? ???? ???? ? ?????? ?? ??? ????? ????? ??????? ?? ?? ??? ???? ??????? ??????? ?????? ??? ???? - ?????? ?????? ?? ????? ?? ? ?????? ???? ????? ?? ???? ???? ??? – ????? ???? ?????? ?? ???? ???? ???? ? ???? ?? ????? ? ? ?? ???? ????? ???? ?? ?? ????? ????? ????? ?????? -?????? ?? ???? ?? ??????

23. Examples of Areas Requiring Design Solutions This slide demonstrates a number of different drugs which have packaging and names which are similar so that one drug could easily be mistaken for another. Examples of Areas Requiring Design Solutions This slide demonstrates a number of different drugs which have packaging and names which are similar so that one drug could easily be mistaken for another.

24. Problems with labelling

25. Improving Labelling and Packagingreduce errors Slide 50 Improving labelling and packaging of methitrexate products The NPSA is working with UK manufacturers to develop patient packs of methotrexate in 16 x 2.5mg’s and 4 x 10mg packs. With alerts emphasising the importance of once weekly treatment and regular blood monitoring. Slide 50 Improving labelling and packaging of methitrexate products The NPSA is working with UK manufacturers to develop patient packs of methotrexate in 16 x 2.5mg’s and 4 x 10mg packs. With alerts emphasising the importance of once weekly treatment and regular blood monitoring.

28. ????? ??? ?????? ???? ?? ?????? ??????? ??????? ? ????? ????? ???? ????? ??? ????? ????? ???? ?? ?????? ? ??????? ????? ? ?????? ??? ????? ????? ???? ?? ????? ????? ?????? ??? ????? ????? ????? ??? ???? ??? ???? ? ??? ????? ????? ??? ??? ???? ??????? ???????? ? ????? ????? ???? ?? ???? ? ?? ????? ???? ?? ?????? ???? ?????? ?????? ???? ????? ?? ???? ?? ????? ?????? ???? ? ????? ???? ?????? ??? ? ???? ?? ???? ?? ?? ????? ?????

29. ??? ???? ?? ?????? ???? ?? ???? ????? ?????? ????? ????? ?????? ???????? ????? ? ??????? ? ??????? ??????? ?????? ?? ????? ????? ???? ????? ????? ??? ????? ????? ????? ????? ???? ??????????? ?? ?? ??? ???? ?????? ?????

30. ??? ???? ?? ?????? ???? (?????) ?????? ??? ?????? ? ?????? ? ????? ??? ?????? ????? ????? ??????? ????? ??? ? ????? ???? ?? ???? ?? ??? ??????? ?????? ???? ?? ????? ?? ???? ?? ??? Damages awarded to patients of the NHS for clinical negligence in 1999-2000 was estimated at £350 million Damages awarded to patients of the NHS for clinical negligence in 1999-2000 was estimated at £350 million

31. ???? ??? ?????? ???? ?????? ?? ??? ?? ????? ?????? ? ?? ???? ????? ???? ??? ?????? ??? ????? ???? ?? ????? ????? ???? ?? ???

32. ?? ??? ?????? ?? ?? ??? ????? ? ??? ????? ??????? ?? ???

33. ?????? ???? ?? ???? ????? ?????: ????? ?????? ??? ?????? ? ????? ???? ??????? ? ??????? ? ? ???? ??? ???? ?? ??????? ? ??????? ? ? ?????? ??????? ? ??? ?? ??? ???? ??? ?????? (Joint commission, 2007)

34. ?????? ???? ?? ?????? ????? ?????? ??? : ??????? ? ????? ? ????? ? ????? ? ? ??????? ?????? ?????? ?? ???? ???? ??? :????? ? ???? ?? ??? ????? ???? ???????

35. ??? ?????? ???? ?? ???????? ???? ???? ???? ???? ???? ????? ???? ?? ???? ????? ?? ???? ??? ???? High Reliability Organizations(HROs) ????? ??????????? ? ?????????? ???? ?? ? ???? ???????? ???????? ??? ???? ?? ????? ?? ?????? ?????? ????? ?????? Evidence from other high risk industries over the past thirty years suggests that in order to improve safety, it is essential to acknowledge that human error is inevitable, and that we must re-design systems to ‘trap’ errors before they lead to harm. These so-called High Reliability Organisations (HROs) have focused on building a culture where adverse events and near misses are valued as opportunities to learn about and fix vulnerable systems. This has resulted in significant improvements in safety and lessons that can be successfully applied to healthcare. In order to do this we must create a culture in health care where staff are encouraged to report incidents without fear. Only then can we understand and fix vulnerable care processes. Effective strategies include a focus on teams, communication and re-design of high-risk processes using a Human Factors Engineering (HFE) approach. Such systems contain forcing functions which reduce the reliance on memory and vigilance (paying attention) and through the effective use of ‘hard-wired’ solutions, unambiguous feedback, displays and instructions, make it difficult for staff to make a mistake (An everyday example of a forcing function is the petrol pump nozzle. The design of the leaded fuel nozzle is such that it cannot physically be introduced into the fuel tank of a vehicle that takes unleaded fuel. It is not necessary to have had training or have read the policy, it is physically impossible to do the wrong thing.) Evidence from other high risk industries over the past thirty years suggests that in order to improve safety, it is essential to acknowledge that human error is inevitable, and that we must re-design systems to ‘trap’ errors before they lead to harm. These so-called High Reliability Organisations (HROs) have focused on building a culture where adverse events and near misses are valued as opportunities to learn about and fix vulnerable systems. This has resulted in significant improvements in safety and lessons that can be successfully applied to healthcare. In order to do this we must create a culture in health care where staff are encouraged to report incidents without fear. Only then can we understand and fix vulnerable care processes. Effective strategies include a focus on teams, communication and re-design of high-risk processes using a Human Factors Engineering (HFE) approach. Such systems contain forcing functions which reduce the reliance on memory and vigilance (paying attention) and through the effective use of ‘hard-wired’ solutions, unambiguous feedback, displays and instructions, make it difficult for staff to make a mistake (An everyday example of a forcing function is the petrol pump nozzle. The design of the leaded fuel nozzle is such that it cannot physically be introduced into the fuel tank of a vehicle that takes unleaded fuel. It is not necessary to have had training or have read the policy, it is physically impossible to do the wrong thing.)

37.  ?????? ?????? ???? ????????? "??????" ? "???????” ?????? ?? ??????? ?? ?????? ????? ??? ??? (??????) ??????? ?? ????? ?????? ?? ?? ?????? ?? ????? ?????? ????? ?? ???? ????? ?? ????? (???????)

38. 7 ????? ?? ?????? ?????? ???? ????? ???? ??????? ???? ????? ???? ??????? ???? ???????? ??? ????? ??? ? ?? ?????? ???? ????? ?????? ????? ???????? ???? ? ??????

39. ?????? ?????? ???? :

40. Assessing and managing risks Explain that risk assessment and management is an ongoing cycle that can be modelled as a series of steps. You could pick a rowing specific example to illustrate the steps in the cycle e.g. a tripping hazard, or use the example of the lion from the zoo. Key learning points The process of assessing and then managing risk can be thought of as a cycle of steps. Risk assessment and management is an ongoing process Steps in assessing risk What hazards are there? Who might be harmed? How could individuals be harmed? What is the level of risk? Steps in managing risk Are existing precautions adequate or should more be done? Record your findings Review your assessment and management of risks and revise if necessary Assessing and managing risks Explain that risk assessment and management is an ongoing cycle that can be modelled as a series of steps. You could pick a rowing specific example to illustrate the steps in the cycle e.g. a tripping hazard, or use the example of the lion from the zoo. Key learning points The process of assessing and then managing risk can be thought of as a cycle of steps. Risk assessment and management is an ongoing process Steps in assessing risk What hazards are there? Who might be harmed? How could individuals be harmed? What is the level of risk? Steps in managing risk Are existing precautions adequate or should more be done? Record your findings Review your assessment and management of risks and revise if necessary

41. ???? ?? ?? ????? ???????? ?? ???? ??????? ????? ??????? ????? ????? ???? ????? ?? ????? ?? ?????? ????? ? ????? ? ????? ?? ? ?????? ?? ? ??? ??? ??????? ?????? ?? ? ????? ?... ?????? ? ????? ????? ? ???????? ????? ? ????? ??? ???? ??????... ?????? ?? ? ??????? ?? ?...

44. ?? ??? ?????? 100 ???? ?? ????? ?? ??? ???? ???? ???? ?? ???? ????? ?? ?????? ??????? ???? ?? ?? ?? ?? ?? ????? ???????? ?? ??????? ?????? ?? ?? ???? ?? ??? ?? ??????

45. ??????? ????

46. ??????? ????

47. ??????? ????

48. ??????? ???? ??? ???? ????? ??? ???? ???? ???? ???? ???? ???? ??? ????? ?????? ???? ???? ???? ????? ??????? ???? ??? ???? ???? ??? ????? ?????? ???? ?? ????? ?? ???? ???? ???? ???? ????. ???? ?????? ?????? ???? ?? ????? ?? ???? ???? ???? ???? ???? ? ??? ???? ???? ????? ???? ???? ?????? ?? ??? ????? ????? Steps in risk assessment and risk management Key learning points Who might be harmed? Participants; rowers and coxes (and family!) Coaches Other water users The public How could individuals be harmed? Harm can include injury, ill health, and death [consider all forms of harm that might occur] Fear of rowing again – sport spoiled Steps in risk assessment and risk management Key learning points Who might be harmed? Participants; rowers and coxes (and family!) Coaches Other water users The public How could individuals be harmed? Harm can include injury, ill health, and death [consider all forms of harm that might occur] Fear of rowing again – sport spoiled

51. ????? ?? ??? ?? ??????? ?? ?? ????

52. Risk Treatment:??????? ??????? ?? ?????? ? ?????? ?? ?????? ?????

55. 7 ????? ?? ?????? ?????? ???? ????? ???? ??????? ???? ????? ???? ??????? ???? ???????? ??? ????? ??? ? ?? ?????? ???? ????? ?????? ????? ???????? ???? ? ??????

56. ?????? ?????? :????? ???? ?? ??? ?????

57.  ?????? ?????? ????  “Reactive” and “Proactive” approaches learning from things that has gone wrong (Reactive) preventing potential risks from impacting in the service that the health organization provides (Proactive)

58.  ?????? ?????? ???? ????????? "??????" ? "???????” ?????? ?? ??????? ?? ?????? ????? ??? ??? (??????) ??????? ?? ????? ?????? ?? ?? ?????? ?? ????? ?????? ????? ?? ???? ????? ?? ????? (???????)

59. Adverse incident ????? ???????? Adverse event ????? ???? ?? ???? Near miss ????? ??? ?? ... Medical error???? ????? Negligent ???? ? ?????? Violation, Fraud ???? ????? ???? Safety ?????

60. ???? ??? ?? ?????? ????? ???? ?? ????: ???? ??? ???????? ?? ??????? ???? ?? ?????? ????? ??? ?? ???? ?????? ????? ???? ??????? ?????? ? ????? ? ?? ???? ??????? ????? ? ????? ???????? ? ??????? "...  Institute of Medicine  Sentinel event :” ????? ??? ?? ?????? ?? ???? ?? ??? ?? ????? ??? ???? ?? ????? ?? ??????? ?? ?? ?? ????“ Joint Commission

61. Sentinel events ????? ??????? ?? ??? ??????????? ?? ????????? ????? ????? ??? ????? ?? ??? ?????? ???? ????? ???? ?? ??? ????? ?????? ??? ?? ??? ????????? ABO  

62. Sentinel events ??? ? ??? ?????? ?? ??? ?? ??? ?? ?????? ????? ???? ?? ??????? ??? ?????? ????? ????? ????? ???? ?????? ???? ?? ??? ?????

63. ??? ???? ???? ??? ? ????? ???????? ? ????? ?? ????? ?? ????? ????????? ?? ?????? ??? ??????? ?? ?? ?????? ?? ????? ???? ???? ??? ????? ???? ??? ???? ?? ????? ? ??????? ???? ???

64. ??? ??? ?????? (???? ?? ????) Proximate (Superficial or obvious) causes ??? ???? ?? (???? ?? ???? ?? ??? ?????? ?? ???) Root Cause(s) ????? ??? ??? The interrelationship of causes

65. ??? ???? ?? ????? ??? ???? ?? ????? ???? ???? ?? ????? ???? ??? ?? ?? ???? ????? ?? ??? ?? ? ?? ?? ???? ???? ????? ? ????? ??? ?? ????? ?? ??? ??????? ?? ???.

66. http://www.thinkreliability.com/Root-Cause-Analysis-CM-Basics.aspx

67. ????? ? ????? ??? ???? ?? ????? (RCA) ??? ?????? ?? ????? ?? ??? ?? ?????? ?? ??? ????? ??? ?? ??????? ????? ????? ????? ??????? ? ?????? ??? ???? ????? ?? ???? ???  ?????? ?? ????? ?? ????? ?????? ??? ”????? ??? ?? ” Near misses???? ??????? ???? ????

68. ??? ?? ????? ? ????? ??? ???? ?? ?? ????? ????? ??????? : ?? ?????? ?????? ???? ??? ????? ????? ???? ?? ???? ?? ????? ???? ??????? ?? ???? ?? ?? ????? ????? ???  ????? ?? ?????? ? ????? ?? ?? ??? ?????? ???? 

69. ????? ? ????? ??? ???? ??(RCA) RCA ???? ?? ?????? ????? ? ????? ??? ?? ?????? ????? ??? Questioning Process ?????? ?? ???? ??????? ? ????? ????? ?? ???.

71. RCA Techniques 5 Whys Safeguard analysis Change analysis Causal factor tree analysis Failure mode and effects analysis Ishikawa diagram (the fishbone diagram or cause and effect diagram) Fault tree analysis

72. ) 5whys5 ???) ?????? ????????? ???? :  ????? ??? ???  ?? ???? ?????? ?? ???? . . .?

73. ????? ?? ?? 5 ??? ???? ???????

74. ????? ? ????? ????????????

75. ????? ????? ???????????? ??????? ????? ?????? ?? ???? ????? ?? ?????? ? ??????? ????? ??? ???? ?? ?????? ?????? ?? ??????? ???????????? ((Safeguards ????? ? ????? ??????? ???? ?????? ???? ???? ????? ???????????? ???? ??????? ? ??????? ?? ???????????? ????

76. ?????? ??????? ????Fishbone Diagram ?? ?? ???? :????? ?? ?????? ???? ?????? ?? ???? ??? ???? :???? ??? ????? ???? ? ?? ???? ???? ??? ????? ???? ?? ?? ???? ???? :???? ??? ???? ???? ??? ???? ?? ???? ????

77. ?????? ??????? ????

78. Fishbone diagram with the NPSA-NHS risk categories in HEALTH

79. ??????? ???? ??? ????? ?? ????? ?? ?????? ?? ????? ?????? ?????? ?????? ?? ?? ??????? ???? ?? ????? ?? ?????? ??? ???? ??? ????? ?? ?????? ???? ??????? ??????? ??????? ?? ???????? ???? ?? ????? ?? ?????? ??? ???? ??? ???? ?? ???? ?? ????? ?? ?????? ?? ????? ?? ???? ????

80. ??????? ???? ??? ??? ?? ???? ??? ?? ??? ???? ?? ?? ????????? ??????? ? ?? ??????? ????? ???? ???? ??? ?? ???? ?? ????? ???? ????? ?????? ??????? ???? ????? ???? ????? ?? ???? ?? ????? ?? ?????? ???? ???? ???? ??? ???? ????? ??????? ??????? ????? ????? ??? ???? ?? ??? ?????? ?????? ??? ????

81. ?????? ????? ? ????? ??? ???? ?? ????????? ??? ??? ???? ??????? ????? ?????? ????? ??? ???? ??????? ??? ???? ?? ??????? ???????? ??? ???? ??? ????????????????? ??????? ??????? ??????? ???? ?????

82. ????? ????? ??? ???? ?? ?????(1) ????? ????? ????? ?????? ?????? ?? ????? ??????? ?? ???? ?? ???? ?????? ???? ?? ????? ???? ???? ?? ?????? RCA ????? ????? ???? ???? ????? ???????? ??? ????? ?????? ?? ????? ?????

83. ????? ????? ??? ???? ?? ????? (2) ??? ????? ?? ??? ?????? ??? ????? ????? ?? ????? ?? ????? ????? ? ????? ??????? ???? ????? ????

84. ?????? ?????? ???? ?? ?????? ???? ????? ??? ?????? ???? ????? ????? ? ???????? ??????? ????? ?? ????? ???? ?? ????? ????????? ?? ?????? ????? ?????? ???? ????? ? ????? ?????? ?? ???????? ??????? ? ????? ???????? ????? ????? ? ???? ????????

85. ?????? ?????? ?????? ???? ???????? ?????? ???? ??????? ??????? ?????? ???? ???? ???? ?????? ???? ?? ??? ?????? ?????? ???????? ? ????? ?? ??????? ??????? ????? ?????? ??? ?????? ???? ?? ?????? ???????

86. ????? ?? ?????? ??? ?? ????? ?? ????? ????? on 2 May 2oo7 ?? (9) ??? ?? ????? ????? the WHO World Alliance for Patient Safety (WAPS) in collaboration with WHO Collaborating Centre for Patient Safety Solutions

87. 9 ??? ?? ????? ????? ???? ?? ??????? ?? ??? ? ???? ????? ??? ??????? ?? ???? ?????? Look-alike, sound-alike medication names ???? ?? ?????? ???? ????? ??? ??????? ?? ??? patient identification ?????? ???? ?? ???? ????? ????? communication during patient hand-overs ????? ??????? ???? ?? ??? ???? ??? ????? performance of correct procedure at correct body site

88. 9 ??? ?? ????? ????? ????? ???? ????? ??? ????????? control of concentrated electrolyte solutions ??????? ?? ??? ???? ?????? ?? ????? ??????? ????? ????? assuring medication accuracy at transitions in care ?????? ????????? ?????? ???? ? ???? ?? avoiding catheter and tubing misconnections

89. 9??? ?? ????? ????? ??????? ???? ?????? ?? ????? ??????? single use of injection devices ????? ?????? ??? ???? ??????? ?? ????? ????? ?? ?????? ??? ?????? improved hand hygiene to prevent health care-associated infection

90. To err is Human To cover up is unforgivable To fail to learn is inexcusable