WELCOME……...

1. 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

2. 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

3. 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

4. Video..

5. ERROR TRAPPING Lines of Defence

6. 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 -

7. 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

8. Case 1Liver Biopsy • 1810h Code Blue (pre MET) • Pale, barely conscious • Returned to Operating theatre • 2 litres of clotted blood & ascites in abdomen

9. 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

10. 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”

11. 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

12. 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

13. 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

14. SYSTEM OBSTACLES • Electronic ordering • Standardised pumps throughout RCH • Programmed intravenous pumps • Standardised Handover practices • Time Out Check • Parents

15. 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.

16. 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