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Learning from Errors to Prevent Harm in Patient Safety Curriculum

Understand the nature of error and how healthcare providers can learn from errors to improve patient safety. Explanation of terms: error, violation, near miss, hindsight bias. Strategies to learn from errors and reduce them.

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Learning from Errors to Prevent Harm in Patient Safety Curriculum

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  1. Topic5 Learningfromerrorstopreventharm PatientSafetyCurriculumGuide

  2. Learningobjective Understandthenatureoferrorandhowhealth-careproviderscanlearnfromerrorstoimprovepatientsafety PatientSafetyCurriculumGuide

  3. Knowledgerequirement • Explaintheterms: • Error • Violation • Nearmiss • Hindsightbias PatientSafetyCurriculumGuide

  4. Performancerequirements: • Knowthewaystolearnfromerrors • Participateintheanalysisofanadverse • event • Practisestrategiestoreduceerrors PatientSafetyCurriculumGuide

  5. Error • Asimpledefinitionis: • “Doingthe wrongthingwhen meaningtodothe rightthing.” • BillRunciman • Amoreformaldefinitionis: • “Plannedsequences ofmental orphysical activities thatfailtoachievetheirintendedoutcomes,whenthesefailurescannotbeattributedtotheinterventionofsomechance agency.” • JamesReason PatientSafetyCurriculumGuide

  6. Note:violation Adeliberatedeviationfromanacceptedprotocolorstandardofcare PatientSafetyCurriculumGuide

  7. Errorsandoutcomes • Errorsandoutcomesarenotinextricablylinked: • Harmcanbefallapatientintheformofacomplicationofcarewithoutanerrorhavingoccurred • Manyerrorsoccurthathavenoconsequenceforthepatientastheyarerecognizedbeforeharmoccurs PatientSafetyCurriculumGuide

  8. Humanfactorsprinciplesremindusthat: • Erroristheinevitabledownsideofhavingabrain! • One definitionof “human error” is “human nature” PatientSafetyCurriculumGuide

  9. Humanbeingsmakemistakes Regardlessoftheirexperience,intelligence,motivationorvigilance,peoplemakemistakes Activity: Thinkaboutandthendiscusswithyourcolleaguesany “sillymistakes”youhavemaderecentlywhenyouwerenotinyourplaceofworkorstudy-andwhyyouthinktheyhappened PatientSafetyCurriculumGuide

  10. Thehealth-carecontextisproblematic • Whenerrorsoccurintheworkplacetheconsequences • can be a problemfor the patient… • …. a situationthat is relatively uniqueto healthcare • Inallotherrespectsthereisnothinguniqueabout • “health-care”errors… • ...theyarenodifferentfromthehumanfactors • problemsthatexistinsettingsoutsidehealthcare PatientSafetyCurriculumGuide 10

  11. Summaryoftheprincipalerrortypes Attentionalslipsofaction Skill-basedslipsandlapses Lapsesofmemory Errors Rule-basedmistakes Mistakes ………… Knowledge-basedmistakes Source:J.Reason PatientSafetyCurriculumGuide

  12. Situationsassociatedwithan increasedriskoferror • Inexperience* • Timepressures • Inadequatechecking • Poorprocedures • Inadequateinformation *Especiallyifcombinedwithlackofsupervision PatientSafetyCurriculumGuide

  13. Individualfactorsthat predisposetoerror • Limitedmemorycapacity • Furtherreducedby: • fatigue • stress • hunger • illness • languageorculturalfactors • hazardousattitudes PatientSafetyCurriculumGuide

  14. Don’tforget …. • Ifyou’re • Hungry • Angry • Late • Tired….. H ALT or PatientSafetyCurriculumGuide

  15. Aperformance-shapingfactors “checklist” • IIllness • MMedication:prescription,over-the-counterand • others • S • A • F • E Stress Alcohol Fatigue Emotion AmIsafetoworktoday? PatientSafetyCurriculumGuide

  16. Incidentreporting/monitoring • Involvescollectingandanalyzinginformationaboutanyeventthatcouldhaveharmedordidharmanyoneintheorganization • Afundamental componentofanorganization’sability • tolearnfromerror PatientSafetyCurriculumGuide

  17. Removingerrortraps • Aprimaryfunctionofanincidentreportingsystemistoidentifyrecurringproblemareas-knownas“errortraps”(J.Reason) • Identifyingandremovingthesetrapsisoneofthe • mainfunctionsoferrormanagement PatientSafetyCurriculumGuide

  18. HindsightBias Beforethe Incident Afterthe Incident ModifiedfromR.Cook,2005,ABriefLookattheNewLookinComplexSystemFailure,Error,SafetyandResilience PatientSafetyCurriculumGuide

  19. Culture:aworkabledefinition 'Sharedvalues(whatisimportant)andbeliefs(howthingswork)thatinteractwithan organization’sstructureand controlsystemstoproducebehavioural norms(thewaywedothingsaroundhere)' JamesReason PatientSafetyCurriculumGuide

  20. Cultureintheworkplace • Itishardto“changetheworld”asajuniorhealth-careprofessional • But… • …you canbeonthelookout forwaystoimprovethe “system” • …youcancontributetothecultureinyourwork • environment PatientSafetyCurriculumGuide 20

  21. Incidentreportingandmonitoringstrategies • Successfulstrategiesinclude: • anonymousreporting • timelyfeedback • openacknowledgementofsuccessesresultingfrom • incidentreporting • reportingofnearmisses • -“free"lessonscanbelearned • -systemimprovementscanbeinstitutedasaresultofthe • investigationbutatno“cost” toa patient • Source:E.B.Larson PatientSafetyCurriculumGuide

  22. Rootcauseanalysis(RCA) • Astructuredapprochtoincidentanalysis • EstablishedbytheNationalCenterforPatientSafetyof • theUSDepartmentofVeteransAffairs • http://www.va.gov/NCPS/curriculum/RCA/index.html PatientSafetyCurriculumGuide

  23. RCAmodel(1) • Arigorous,confidentialapproachtoanswering: • Whathappened? • Whowasinvolved? • Whendidithappen? • Wheredidithappen? • Howseverewastheactualorpotentialharm? • Whatisthelikelihoodofrecurrence? • Whatweretheconsequences? PatientSafetyCurriculumGuide

  24. RCAmodel(2) • Focusesonprevention,notblameorpunishment • Focusesonsystemlevelvulnerabilitiesratherthanindividualperformance • Itexaminesmultiplefactorssuchas: • communication • training • fatigue/scheduling • -environment/equipment • rules/policies/procedures • barriers PatientSafetyCurriculumGuide

  25. Personalerrorreductionstrategies • Knowyourself:eatwell,sleepwell,lookafteryourself • Knowyourenvironment • Knowyourtask(s) • Preparationandplanning;“Whatif…?” • Build“checks”into yourroutine • Askif youdon’t know! PatientSafetyCurriculumGuide

  26. Mentalpreparedness • Assumethaterrorscanandwilloccur • Identifythosecircumstancesmostlikelytobreed • error • Havecontingenciesinplacetocopewithproblems,interruptionsanddistractions • Mentallyrehearsecomplexprocedures JamesReason PatientSafetyCurriculumGuide

  27. Summary • Health-careerrorisacomplexissue,buterroritselfisan • inevitablepartofthehumancondition • Learningfromerrorismoreproductiveifitisconsideredatanorganizationallevel • Rootcauseanalysisisahighlystructuredsystem • approachtoincidentanalysis PatientSafetyCurriculumGuide

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