Describe the traditional view of Safety
- Safety 1 = absence of accidents
- Focusses on when things go wrong
- What caused the failure
- How can we prevent the failure
Describe the new view of Safety
- Focuses on understanding normal performance, variability, flexibility, and resilience
- Know that usually there are no mistakes but occasionally things go wrong
What is an error of commission and give an example in health care context
Actions that should not have been done or was done incorrectly e.g. wrong dose
What is an error of omission and give an example in health care context
Action that was not done e.g. missed diagnosis
What do errors of omission and commission focus on?
What was done, not why it was done
What is a violation defined as?
Deliberate deviations from ‘what one ought to do’ e.g. working over set hours
What can an unintentional error caused by?
Cognitive failures
What are the two types of unintentional errors?
- Slips
2. Lapses
Describe a ‘Slip’ and state what error type it is
- Unintended action therefor an error of commission
- e.g. wrong instructions given
Describe ‘Lapses’ and state what error type it is
Unintended error of omission e.g. missed step in the procedure
What is a mistake?
Actions are planned to be correct but don’t work out
What are the different types of mistakes and describe each one?
- Rule based = operator misapplies/doesn’t follow the rule
- Knowledge based = operators knowledge of world is inadequate for them to take action
- Skill based = (physical) skills are inadequate / inadequately applied
Describe the use of Evaluating Error using Reason’s Taxonomy
- Errors are categorised using Reason’s taxonomy
- > knowledge based mistakes
- > rule based mistakes
- > skill based mistakes
- > technical error
- > system based problem
- Look at the mitigating factors
- Evaluate a strategy
What is an Electronic Health Record?
A longitudinal record compiling all medical history and appointments
What are the benefits of an Electronic Health Record?
- Comprehensive
- Standardised and accessible to collate population data/trends
What are the negatives of an Electronic Health Record?
- Places more responsibility on the Dr
- Decreases interview flow and rapport
- People don’t know where their private info is being used
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