This document discusses learning from errors in healthcare to improve patient safety. It defines key terms like error, violation and near miss. It explains that error is inevitable given human fallibility but the healthcare context makes errors particularly problematic when harm occurs. Learning from errors requires analyzing adverse events, understanding contributing factors beyond individual blame, and implementing strategies and systems to reduce future risk and prevent harm.
Patient safety in Healthcare; Developing Patient Safety Culture by reporting ...VENODEN DHARMARAJAN
A guide and stimulant for the Medical Professionals on Patient Safety.
Patient safety is defined as the prevention and reduction of adverse outcomes (Alahmadi,2009). Learning from the mistake is the key to improve patient safety.
12.9% of admissions to public hospital in New Zealand is associated with a hospital adverse event.
10% of such admissions in UK
7.5% of such admissions in Canada
2.5 billion of Euros are spent yearly for compensation due to mistakes in hospitals in Italy
Active failure
It is related to errors of procedures or treatment at the site of the action
Latent failure
It is related to design failure, building failure and regulatory and procedure failures.
Active errors
occur at the level of the frontline operator
their effects are felt almost immediately
Latent errors
Not under the direct control of the operator
poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organizations
The safety culture of an organisation is the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety management.”
Quality, which is much more complex and comprehensive than what we understand, can be defined and described in many ways by taking account of what we produce and serve and also what our customers experience. Service Quality is multidimensional and depends not only technical quality but also in a greater way on functional quality. Health Service is a complex subject depending on fulfilling medical and health related non-medical needs
Patient safety in Healthcare; Developing Patient Safety Culture by reporting ...VENODEN DHARMARAJAN
A guide and stimulant for the Medical Professionals on Patient Safety.
Patient safety is defined as the prevention and reduction of adverse outcomes (Alahmadi,2009). Learning from the mistake is the key to improve patient safety.
12.9% of admissions to public hospital in New Zealand is associated with a hospital adverse event.
10% of such admissions in UK
7.5% of such admissions in Canada
2.5 billion of Euros are spent yearly for compensation due to mistakes in hospitals in Italy
Active failure
It is related to errors of procedures or treatment at the site of the action
Latent failure
It is related to design failure, building failure and regulatory and procedure failures.
Active errors
occur at the level of the frontline operator
their effects are felt almost immediately
Latent errors
Not under the direct control of the operator
poor design, incorrect installation, faulty maintenance, bad management decisions, and poorly structured organizations
The safety culture of an organisation is the product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety management.”
Quality, which is much more complex and comprehensive than what we understand, can be defined and described in many ways by taking account of what we produce and serve and also what our customers experience. Service Quality is multidimensional and depends not only technical quality but also in a greater way on functional quality. Health Service is a complex subject depending on fulfilling medical and health related non-medical needs
Tools for Risk Assessment in Nursing - Return to Nursing ProgramIHNA Australia
Clinical Risk Assessment Tools are specific assessments that are used to measure levels of risk for certain situations, procedures and outcomes in hospitals and other healthcare settings.
In the clinical setting, nurses use a variety of clinical risk assessment tools that will help with the patients care.
This presentation will provide an outline of two key risk assessment tools:
1. Braden Scale, which is used to predict pressure sore risk.
2. Falls Risk Assessment, which is used to predict the likelihood of a fall occurring.
Risk assessment scales and screenshots of relevant forms are included in this presentation.
This presentation was compiled by Gulzar Malik, an experienced and qualified Nursing Educator at IHNA. For more information about our return to nursing programs, please call 1800 22 52 83.
A discussion of key issues in relation to short incubation (rapid) HIV testing in a non-clinical setting. This presentation By Stevie Clayton of ACON was given at the AFAO AGM workshops November 2007.
Objectives:
1.Introduce the Measuring and Monitoring of Safety Framework to a Canadian healthcare audience
2.Describe how the framework would work in Canada
Creating an individualized, patient-specific care plan that includes a comprehensive review of all problems, a clear set of unified goals, and an integrated care strategy with meaningful interventions is paramount to the standard practice of case management. However, that is easier said than done.
Interested in medical and nursing both refer to a career guide noww3Education
So you want to opt for a career in healthcare, right? But are you confused about the right profession? Is choosing between medical and nursing a growing concern for you?
Tools for Risk Assessment in Nursing - Return to Nursing ProgramIHNA Australia
Clinical Risk Assessment Tools are specific assessments that are used to measure levels of risk for certain situations, procedures and outcomes in hospitals and other healthcare settings.
In the clinical setting, nurses use a variety of clinical risk assessment tools that will help with the patients care.
This presentation will provide an outline of two key risk assessment tools:
1. Braden Scale, which is used to predict pressure sore risk.
2. Falls Risk Assessment, which is used to predict the likelihood of a fall occurring.
Risk assessment scales and screenshots of relevant forms are included in this presentation.
This presentation was compiled by Gulzar Malik, an experienced and qualified Nursing Educator at IHNA. For more information about our return to nursing programs, please call 1800 22 52 83.
A discussion of key issues in relation to short incubation (rapid) HIV testing in a non-clinical setting. This presentation By Stevie Clayton of ACON was given at the AFAO AGM workshops November 2007.
Objectives:
1.Introduce the Measuring and Monitoring of Safety Framework to a Canadian healthcare audience
2.Describe how the framework would work in Canada
Creating an individualized, patient-specific care plan that includes a comprehensive review of all problems, a clear set of unified goals, and an integrated care strategy with meaningful interventions is paramount to the standard practice of case management. However, that is easier said than done.
Interested in medical and nursing both refer to a career guide noww3Education
So you want to opt for a career in healthcare, right? But are you confused about the right profession? Is choosing between medical and nursing a growing concern for you?
patient safety and staff Management system ppt.pptxanjalatchi
Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
patient safety and staff Management system ppt.pptxanjalatchi
What is Patient Safety? Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
System design to produce safer care culture meassurement and infrastructure f...Proqualis
Apresentação de Carol Haraden durante o SIMPÓSIO EINSTEIN-IHI: Implantação e Disseminação de Programas de Segurança do Paciente aconteceu de 3 a 5 de novembro de 2013, em São Paulo - Brasil.
Carol Haraden é PhD, Vice Presidente do Institute for Healthcare Improvement (IHI), é membro do time responsável por desenvolver desenhos inovadores no cuidado ao paciente. Atualmente, ela lidera os trabalhos do IHI na Escócia, Sul da Inglaterra, Dinamarca e Estados Unidos.
Applying the Science of High Reliability to Improve Operations and Increase...Health Catalyst
Principles of high reliability have been a strategic focus for many hospitals and healthcare systems. Still, significant disruptions, such as the COVID-19 pandemic, often push strategic initiatives aside or categorize them as “not important right now.” However, high-reliability organizations (HROs) principles and practices are essential in uncertain times to support operations and organizational resilience.
Fran Griffin, an independent consultant with over 25 years of experience in healthcare—specializing in the areas of patient safety, quality improvement, and high reliability—discusses the characteristics of HROs and how to apply these principles in both expected and unexpected situations. Fran discusses approaches to process design and analysis, movement from “Safety 1 to Safety 2,” and the impact on organizational culture. She also shares strategies for self-assessing an organization’s progress on the high-reliability journey.
After this webinar, attendees will be able to:
-Describe how high-reliability practices support operations in both expected and unexpected situations.
-Summarize key concepts from Safety 2 approaches.
-Apply self-assessment methods to their organization.
-Identify opportunities for design and redesign using HRO principles.
The implementation of Risk management in a health care organisation ensure safe health care,increased patient satisfaction , improved bottom line and brand value.
Personal Brand Statement:
As an Army veteran dedicated to lifelong learning, I bring a disciplined, strategic mindset to my pursuits. I am constantly expanding my knowledge to innovate and lead effectively. My journey is driven by a commitment to excellence, and to make a meaningful impact in the world.
Event Report - SAP Sapphire 2024 Orlando - lots of innovation and old challengesHolger Mueller
Holger Mueller of Constellation Research shares his key takeaways from SAP's Sapphire confernece, held in Orlando, June 3rd till 5th 2024, in the Orange Convention Center.
Building Your Employer Brand with Social MediaLuanWise
Presented at The Global HR Summit, 6th June 2024
In this keynote, Luan Wise will provide invaluable insights to elevate your employer brand on social media platforms including LinkedIn, Facebook, Instagram, X (formerly Twitter) and TikTok. You'll learn how compelling content can authentically showcase your company culture, values, and employee experiences to support your talent acquisition and retention objectives. Additionally, you'll understand the power of employee advocacy to amplify reach and engagement – helping to position your organization as an employer of choice in today's competitive talent landscape.
Company Valuation webinar series - Tuesday, 4 June 2024FelixPerez547899
This session provided an update as to the latest valuation data in the UK and then delved into a discussion on the upcoming election and the impacts on valuation. We finished, as always with a Q&A
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Putting the SPARK into Virtual Training.pptxCynthia Clay
This 60-minute webinar, sponsored by Adobe, was delivered for the Training Mag Network. It explored the five elements of SPARK: Storytelling, Purpose, Action, Relationships, and Kudos. Knowing how to tell a well-structured story is key to building long-term memory. Stating a clear purpose that doesn't take away from the discovery learning process is critical. Ensuring that people move from theory to practical application is imperative. Creating strong social learning is the key to commitment and engagement. Validating and affirming participants' comments is the way to create a positive learning environment.
Implicitly or explicitly all competing businesses employ a strategy to select a mix
of marketing resources. Formulating such competitive strategies fundamentally
involves recognizing relationships between elements of the marketing mix (e.g.,
price and product quality), as well as assessing competitive and market conditions
(i.e., industry structure in the language of economics).
2. Learning objective
Understand the nature of error and how healthcare providers can learn from errors to improve
patient safety
Patient Safety Curriculum Guide
2
4. Performance requirements:
Know the ways to learn from errors
Participate in the analysis of an adverse
event
Practise strategies to reduce errors
Patient Safety Curriculum Guide
4
5. Error
A simple definition is:
“Doing the wrong thing when meaning to do the
right thing.”
Bill Runciman
A more formal definition is:
“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.”
James Reason
Patient Safety Curriculum Guide
5
6. Note: violation
A deliberate deviation from an accepted
protocol or standard of care
Patient Safety Curriculum Guide
6
7. Errors and outcomes
Errors and outcomes are not inextricably linked:
• Harm can befall a patient in the form of a
•
complication of care without an error having
occurred
Many errors occur that have no consequence
for the patient as they are recognized before
harm occurs
Patient Safety Curriculum Guide
7
8. Human factors principles
remind us that:
Error is the inevitable downside of having a brain!
One definition of “human error” is “human nature”
Patient Safety Curriculum Guide
8
9. Human beings make mistakes
Regardless of their experience, intelligence, motivation
or vigilance, people make mistakes
Activity:
Think about and then discuss with your colleagues
any “silly mistakes” you have made recently when
you were not in your place of work or study - and why
you think they happened
Patient Safety Curriculum Guide
9
10. The health-care context is problematic
When errors occur in the workplace the consequences
can be a problem for the patient…
…. a situation that is relatively unique to health care
In all other respects there is nothing unique about
“health-care” errors…
... they are no different from the human factors
problems that exist in settings outside health care
Patient Safety Curriculum Guide
10
11. Summary of the principal error types
Attentional slips
of action
Skill-based slips
and lapses
Lapses of
memory
Errors
Rule-based
mistakes
Mistakes
…………
Source: J. Reason
Knowledgebased mistakes
Patient Safety Curriculum Guide
11
12. Situations associated with an
increased risk of error
Inexperience*
Time pressures
Inadequate checking
Poor procedures
Inadequate information
* Especially if combined with lack of supervision
Patient Safety Curriculum Guide
12
13. Individual factors that
predispose to error
Limited memory capacity
Further reduced by:
• fatigue
• stress
• hunger
• illness
• language or cultural factors
• hazardous attitudes
Patient Safety Curriculum Guide
13
14. Don’t forget ….
If you’re
• Hungry
• Angry
• Late
or
• Tired …..
H
A
L
T
Patient Safety Curriculum Guide
14
15. A performance-shaping factors “checklist”
I Illness
M Medication: prescription, over-the-counter and
others
S
A
F
E
Stress
Alcohol
Fatigue
Emotion
Am I safe to work today?
Patient Safety Curriculum Guide
15
16. Incident reporting/monitoring
Involves collecting and analyzing information about
any event that could have harmed or did harm anyone
in the organization
A fundamental component of an organization’s ability
to learn from error
Patient Safety Curriculum Guide
16
17. Removing error traps
A primary function of an incident reporting system is
to identify recurring problem areas - known as “error
traps” (J.Reason)
Identifying and removing these traps is one of the
main functions of error management
Patient Safety Curriculum Guide
17
18. Hindsight Bias
Before the
Incident
After the
Incident
Modified from R. Cook, 2005, A Brief Look at the New Look in Complex System Failure, Error, Safety and Resilience
Patient Safety Curriculum Guide
18
19. Culture: a workable definition
'Shared values (what is important) and
beliefs (how things work) that interact
with an organization’s structure and
control systems to produce behavioural
norms (the way we do things around here)'
James Reason
Patient Safety Curriculum Guide
19
20. Culture in the workplace
It is hard to “change the world” as a junior health-care
professional
But …
…you can be on the look out for ways to improve the
“system”
… you can contribute to the culture in your work
environment
Patient Safety Curriculum Guide
20
21. Incident reporting and monitoring
strategies
Successful strategies include:
• anonymous reporting
• timely feedback
• open acknowledgement of successes resulting from
•
incident reporting
reporting of near misses
-“free" lessons can be learned
- system improvements can be instituted as a result of the
investigation but at no “cost” to a patient
Source: E.B. Larson
Patient Safety Curriculum Guide
21
22. Root cause analysis (RCA)
A structured approch to incident analysis
Established by the National Center for Patient Safety of
the US Department of Veterans Affairs
http://www.va.gov/NCPS/curriculum/RCA/index.html
Patient Safety Curriculum Guide
22
23. RCA model (1)
A rigorous, confidential approach to answering:
What happened?
Who was involved?
When did it happen?
Where did it happen?
How severe was the actual or potential harm?
What is the likelihood of recurrence?
What were the consequences?
Patient Safety Curriculum Guide
23
24. RCA model (2)
Focuses on prevention, not blame or punishment
Focuses on system level vulnerabilities rather than
individual performance
It examines multiple factors such as:
- communication
- environment/equipment
- training
- rules/policies/procedures
- fatigue/scheduling - barriers
Patient Safety Curriculum Guide
24
25. Personal error
reduction strategies
Know yourself: eat well, sleep well, look after yourself
Know your environment
Know your task(s)
Preparation and planning; “What if …?”
Build “checks” into your routine
Ask if you don’t know!
Patient Safety Curriculum Guide
25
26. Mental preparedness
Assume that errors can and will occur
Identify those circumstances most likely to breed
error
Have contingencies in place to cope with problems,
interruptions and distractions
Mentally rehearse complex procedures
James Reason
Patient Safety Curriculum Guide
26
27. Summary
Health-care error is a complex issue, but error itself is an
inevitable part of the human condition
Learning from error is more productive if it is considered at
an organizational level
Root cause analysis is a highly structured system
approach to incident analysis
Patient Safety Curriculum Guide
27