Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health professional, patient or consumer.
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What are the issues with Medicines?
Adverse drug events, Adverse drug reactions, Adherence problems, Medication errors
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Why is it important to worry about errors in primary care?
Prescribing/monitoring errors, dispensing errors, preventable adverse drug events, preventable adverse drug events causing hospitalisation
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What does the Francis report, Keogh Review and the Berwick Report (2013) recommend?
All recommend to increase transparency and honesty-being open.
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What is Punitive culture?
This includes blame and punishment. There is a culture of fear. This includes a fear to report and encourages concealing when something goes wrong.
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What is No Blame Culture?
Blanket immunity, lack of accountability. This is unfair and can be abused.
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What is Just Culture?
This suggests open culture (transparency/discussion), reporting culture, learning from mistakes. This creates a safety culture.
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What are the 4 principles of Patient Safety Incidents?
1. Patient safety important 2. Not tolerate deliberate harm 3. Healthcare professionals raising concerns and learning from incidences 4. Individual accountability always fair and proportionate.
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Define 'Duty of Candour'?
A legal duty of hospital, community and mental health trusts to inform and apologise to patients if there have been mistakes in care that have lead to significant harm.
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What are the aims of duty of candour?
Help patients receive accurate, truthful info from health providers. Create a wholly transparent culture (open when errors are made and harm is caused)
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Who do NHS providers need to be registered with to comply with a new duty of candour?
Care Quality Commission (CQC)
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What are the aims of incident reporting?
Learn from errors and near misses, establish nationwide solutions, prevent further errors
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What are the 6 professional standards?
Open and honest, Report, learn, share, act, review
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Why do people not report incidents?
Time, Benefits unclear, lack of knowledge, fear and anxieties
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What are the laws for defence for inadvertent dispensing errors?
The Pharmacy Order 2018, Medicines Act 1968
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For the Defence for Inadvertent Dispensing errors, what are the 2 criteria that have to be met?
did not know that the medicine was not the required nature/quality, on becoming aware of the inappropriateness of medicine all reasonable steps were taken to notify person.
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Name some examples of changes to working practices that have been implemented?
Changes to medication packaging, changing connectors for intrathecal injections, introducing tabards for drug refunds, introducing greater controls on warfarin monitoring
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What is a never event?
A particular type of serious incident that meet all the following criteria.
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What are the criteria of a Never event?
Wholly preventable, potential to cause serious harm/death, evidence that never event has happened in the past, easily recognised and clearly defined
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State some never events to do with Medication?
mis-selection of a strong potassium chloride solution, administration of medication by the wrong route, overdose of insulin due to abbreviations or incorrect device
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State some never events to do with Surgery?
wrong site surgery, wrong implant, retained foreign object post procedure
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State a never events to do with mental health?
Failure to install functional collapsible shower or curtain rails.
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What is a 'Human factors' approach?
“Human factors encompass all those factors that can influence people and their behaviour. In a work context, human factors are the environmental, organisational and job factors, and individual characteristics which influence behaviour at work.”
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Other cards in this set
Card 2
Front
What are the issues with Medicines?
Back
Adverse drug events, Adverse drug reactions, Adherence problems, Medication errors
Card 3
Front
Why is it important to worry about errors in primary care?
Back
Card 4
Front
What does the Francis report, Keogh Review and the Berwick Report (2013) recommend?
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