Errors occur due to a combination of active failures and latent conditions that create opportunities for mistakes.
A flash fire ensued because the CRNA did not hear the surgeon's request to turn off the oxygen, resulting in severe burns to half of her face.
It refers to a state where individuals perform tasks without conscious awareness, often leading to unintentional errors.
It emphasizes making harm visible so that it can be addressed and fixed.
There are deficiencies in the documents – policies, procedures, and job aids – that are intended to support the work process and guide individual decision making.
Patient safety and harm reduction.
A missed diagnostic error occurs when no diagnosis was made, although information existed to make a correct diagnosis.
The 'Read Back' technique involves the receiver repeating the information back to the sender to confirm accuracy.
It measures the rolling 12-month rate of Serious Safety Events per 10,000 adjusted patient days in hospitals or per 100,000 patient visits in medical groups.
Clear communication ensures that information is accurately conveyed and understood, reducing the risk of errors.
Wrong side surgery.
There are deficiencies in the documents – policies, procedures, and job aids – that are intended to support the work process and guide individual decision making.
It involves collecting and analyzing information about any event that could have harmed or did harm anyone in the organization.
It can reduce error rates by 10 to 100 times.
You should ask 1 or 2 clarifying questions to ensure you understand what you are supposed to do.
23 deaths annually from medical error.
Performance expectations should include internal policies, nationally recognized standards of care, industry-imposed practice mandates, professional practice standards, and the organization's obligation to protect the patient from harm.
An incorrect diagnostic error is when a diagnosis was made, but the diagnosis was wrong.
First, do no harm.
The cost of doing business in a highly complex healthcare system.
It involves considering what could go wrong and not ignoring risks or small errors.
There are deficiencies in the design of the expectations or flow of the work process expectations.
To identify recurring problem areas known as 'error traps'.
Redesign so that the error-prone task is no longer necessary.
Significant safety, quality, or service issues from the past 24 hours.
The SEC is designed to categorize safety events to facilitate analysis and improve patient safety.
The safety phrase is: 'Let me ask a clarifying question...'
Human error should be the starting point, not the conclusion.
The design of the workplace, equipment, and information systems makes it difficult for the person to carry out the task at hand.
It suggests that while making mistakes is human, continuing to make the same mistakes is unacceptable.
The captain had not established a good foundation of instrument flying skills, and his weaknesses in basic aircraft control and instrument flying were not identified and adequately addressed.
The organization did not provide the people, resources, or oversight to support the process or activity being performed.
It refers to Skill-Based Performance.
Infection, fall, delayed diagnosis causing delay in treatment, among others.
Alerts lead to alert fatigue.
Reluctance to Simplify: Ask questions and avoid assumptions.
Quebec
It is essential for an organization’s ability to learn from error.
The report highlighted the prevalence of medical errors and the need for improved patient safety.
Fatal transfusion reaction.
Figure out what you would click next.
The organization’s values and behavior expectations for leaders, physicians, and staff serve as a counter-influence to safe, reliable individual and team performance.
Deviations from GAPS are identified by comparing actual performance to expected performance.
The procedure was performed on the wrong patient.
Anonymous reporting, timely feedback, open acknowledgment of successes, reporting of near misses.
Situation: The bottom line (diagnosis, current condition, problem).
It suggests that people who make mistakes are poor performers.
A CT scan was recommended.
It smooths out the rate for infrequent events and encourages sustainability of performance.
Fatal electrolyte error.
Note the time in seconds when done.
It shows how most errors occur due to a combination of failures at the 'blunt' (system) end and common human failures at the 'sharp' end.
Identifying and removing error traps.
Over 400,000 deaths annually.
By replacing a manual task with an automated one.
Sarah's daughter was delivered stillborn after the care team failed to voice their concerns about significant drops in the baby's heart rate.
Competency refers to the person not having the knowledge or well-developed skill to perform the task.
As in 0.9
A delayed diagnostic error happens when a correct diagnosis was made, but information existed to make the diagnosis earlier.
'That’s correct!' is a codeword indicating that both parties understand each other.
There are deficiencies in the design of the expectations or flow of the work process expectations.
The organization did not provide the people, resources, or oversight to support the process or activity being performed.
Pilot error and poor training were blamed for the crash, along with the pilots' performance likely being impaired due to fatigue.
Almost one patient every other week.
Skill-Based Performance, Rule-Based Performance, Knowledge-Based Performance.
Between 48,000 and 95,000 preventable deaths per year.
The organization’s values and behavior expectations for leaders, physicians, and staff serve as a counter-influence to safe, reliable individual and team performance.
They are considered a reason for errors in the expectations or flow of the work process.
Background: What do you know? (medical history, past tests or treatments).
Transparency is crucial because it fosters trust, encourages reporting of errors, and facilitates the collection, analysis, and sharing of safety data, which is essential for reducing harm.
Introduction and Basic Principles of Patient Safety.
The design of the workplace, equipment, and information systems can make it difficult for the person to carry out the task at hand.
The design of the workplace, equipment, and information systems makes it difficult for the person to carry out the task at hand.
Active failures or unsafe acts, such as slips, lapses, mistakes, and violations, can occur.
Shortages of medical scanners, equipment downtime, and personal health issues like migraines.
Identifying system errors and potential solutions, recognizing that error prevention requires a system approach.
If Anna's nurses or physician had attempted to validate her complaints rather than assuming they were due to anxiety.
It explains why the plan needs to happen.
The patient tried to hang himself on the shower curtain rod, which broke.
People experience slips, lapses, and fumbles when rushing, distracted, multitasking, or fatigued.
A Repeat-Back is a communication technique where one party repeats back what another party has said to confirm understanding.
A symptom, not the cause of failure.
Poorly designed processes, unusual situations, failures in education and training, distractions, failures in critical thinking, and individual choices not to comply with standards.
GAPS are standards determined by comparing actual performance to expected performance.
Adam put weight on his knee, which tore much of the surgical repair, requiring additional surgery.
The design of the workplace, equipment, and information systems makes it difficult for the person to carry out the task at hand.
It refers to Knowledge-Based Performance.
The organization did not provide the people, resources, or oversight to support the process or activity being performed.
Scanners lead to poor self-checking.
Power of the Pause.
The patient safety movement in the US originated in response to increasing awareness of medical errors and their impact on patient outcomes, leading to initiatives aimed at improving healthcare quality and safety.
Sensitivity, honesty, compassion, empathy, making appropriate referrals, delivering bad news, informed consent, and disclosure of medical errors.
Stop and address that concern in a respectful manner, regardless of whether the concern is unfounded.
A small group exercise on error reporting.
Deference to Expertise: Don’t hesitate to share your expertise.
The Swiss Cheese Model illustrates how system flaws can lead to errors, emphasizing the need to identify and close 'holes' in safety strategies.
To catch each other’s errors and mistakes, hold each other accountable for expectations, and benefit from each other’s experience.
By mitigating the impact of a process failure.
Reluctance to simplify and making assumptions.
Echo
Tango
That's five - zero
Statements such as 'The patient was going to die anyway', 'The patient was a DNR', and 'We don’t know for sure why the patient died' do not impact this determination.
It helps in deciding the appropriate response and actions to take following a safety event.
A safety phrase is 'Let me repeat that back…' which helps ensure clarity in communication.
The organization’s values and behavior expectations for leaders, physicians, and staff serve as a counter-influence to safe, reliable individual and team performance.
When results are different than expected, when something 'doesn't feel right' or doesn't make sense, and all the time.
To ensure work activities are stopped when faced with uncertainty to minimize the chance of a high-risk situation harming a patient or associate.
HROs strive to make systems ultra-safe to decrease the chance of errors.
Preoccupation with Failure: Consider what could go wrong.
The coffee costs $0.05.
Lead by example and participate actively.
Deficiencies in the documents – policies, procedures, and job aids – intended to support the work process can lead to errors.
Sensitivity, honesty, compassion, empathy, making appropriate referrals, delivering bad news, informed consent, and disclosure of medical errors.
It entails bouncing back from the unexpected.
Communication errors occur when a person hears information incorrectly or misinterprets its meaning.
To see if either party has any questions.
Progressive disease in the lungs.
Anna died from acute respiratory distress syndrome after her complaints were assumed to be anxiety.
He was placed on a ventilator with a poor prognosis.
Each defence in the system is seen as having holes, which can arise from active failures and latent conditions.
India
X-Ray
We need the Be Safe Tools because we are all human and make mistakes, there are poorly designed processes or systems, and individual choices may lead to non-compliance with standards.
ZERO HARM.
Reporting helps safety and risk leaders to understand and address potential issues daily.
Effective handovers should provide unambiguous transfer of responsibility, promote a shared mental model, occur in protected time and space, minimize interruptions, include up-to-date information, involve family participation, and follow a standardized format.
Forcing functions lead to work-arounds.
A chest x-ray revealing diffuse lung nodules.
System improvements can be instituted at no cost to a patient.
There are deficiencies in the design of the expectations or flow of the work process expectations.
Assessment: What is happening now? (current findings, needs, concerns).
The Accident Causation Model, also known as the Swiss Cheese Model, illustrates how errors occur when multiple layers of defense fail, highlighting the importance of both system and individual factors in error causation.
Decision support leads to poor critical thinking.
By adding requirements designed to detect mistakes.
It gives your brain a chance to catch up with what your hands are about to do.
Plan-Do-Study-Act, used in applying Continuous Quality Improvement.
Clinical Application of Medical Ethics, Informed Consent, Decisional Capacity, and Competency.
It outlines what should happen next.
A system has a ‘sharp end’ and a ‘blunt end’.
There are deficiencies in the design of the expectations or flow of the work process expectations.
Whiskey
That's four - five
The organization did not provide the people, resources, or oversight to support the process or activity being performed.
To improve critical thinking by encouraging people to internally question things they hear and see.
It refers to being aware of what is happening around you in the healthcare environment.
Embrace transparency.
Circumcision
10 percent of U.S. deaths are due to preventable medical mistakes.
Stop… Pause for 1 to 2 seconds to focus our attention on the task at hand.
Deference to Expertise
Organizing and prioritizing responsibilities while understanding systems, economics, and laws/policies to provide safe, effective, and efficient care.
It posits that all people are fallible and that system factors are the majority cause of error.
Consciousness implies that the person knows what to do but fails to carry out the task correctly due to distraction.
Disclosing medical errors effectively.
High Reliability principles focus on creating a culture of safety, continuous learning, and resilience, which collectively lead to significant reductions in errors and enhance patient safety in clinical practice.
Critical Thinking involves the cognitive processing of information, and failure in this area can lead to poor decision making.
Compliance means the person is aware of performance expectations but chooses to act differently.
Knowledge, skills, coping mechanisms, conflict between professional and personal responsibilities, and emotional limitations.
A debrief is a discussion by the team about how a procedure went.
Promoting the well-being of healthcare providers.
There are deficiencies in the documents – policies, procedures, and job aids – that are intended to support the work process and guide individual decision making.
Foxtrot
Oscar
Uniform
The therapist should take the time to validate and verify the order in the chart.
Safety coaches should update their team monthly on events reported in their area.
By building a culture of safety and using 'be safe' behaviors in daily operations.
It signifies Rule-Based Performance.
'Free' lessons can be learned from the reporting of near misses.
It emphasizes knowing what’s going on around you.
The Blunt End refers to where care is designed, highlighting that processes can be flawed.
Errors can occur due to communicating in a hurry, similar-sounding words, discomfort in asking questions, communication via cell phones, and language proficiency issues.
There are deficiencies in the documents – policies, procedures, and job aids – that are intended to support the work process and guide individual decision making.
The 'sharp end' and the 'blunt end'.
Anyone you work with.
Coach off-line to provide constructive feedback.
To perform second checks and double checks.
If the whole series of defenses is penetrated, it can lead to a trajectory of 'accident opportunity'.
Intended to dispense the second item on prescription but forgot about it and failed to give it to the patient.
The organization’s values and behavior expectations for leaders, physicians, and staff serve as a counter-influence to safe, reliable individual and team performance.
Delta
November
Sierra
The NTSB concluded that the pilots' performance was likely impaired because of fatigue.
To point out problems in a positive manner and ensure accuracy before proceeding with high-risk tasks.
The organization’s values and behavior expectations for leaders, physicians, and staff serve as a counter-influence to safe, reliable individual and team performance.
Look Back, Look Ahead, Follow Up.
To determine if the source of information is credible.
Independent checks lead to co-dependency.
They facilitate by providing reminders and cues.
Thank those that participate.
The ultrasound report was not available for the patient.
Use the QV&V Technique: Qualify, Validate, and Verify.
Consider what problems prevent safe work, what system factors have led to errors, and what 'holes' need to be closed for better safety strategies.
Started driving to the airport, but fell into mental ‘autopilot’ and took the route to work instead.
Payors, Providers, and Patients (Consumers).
They indicate what could be expected to be different or unusual about the situation.
The design of the workplace, equipment, and information systems makes it difficult for the person to carry out the task at hand.
Golf
Papa
That's four - two - five
Brief, Execute and Debrief
Performed a brief Time Out.
By providing positive feedback when you catch someone doing it right and discouraging unsafe behaviors.
Think… Consider the action you’re about to take.
Design components so that a mistake is impossible.
Act… Concentrate and carry out the task.
Recommendation: What is next? (recommendation or request for plan of care).
Review… Check to make sure that the task was done correctly and that you got the correct result.
Giving report electronically leads to a loss of situational awareness.
The RN contacted Maria’s physician and requested a transvaginal ultrasound to ensure the patient was not harmed.
Fetal heart tones were identified, leading to the cancellation of the D&C.
A brief is a discussion of the team plan for a procedure.
Improving patient experience, improving population health, and reducing costs.
A trajectory of ‘accident opportunity’ arises.
Bravo
Kilo
Victor
A Safety Event is any incident that results in harm or has the potential to cause harm. Serious safety events result in significant harm, precursor events indicate potential for harm without actual harm occurring, and near miss events are incidents that could have resulted in harm but did not.
They include understanding systems, economics, and laws/policies to provide care that is safe, effective, and efficient.
Ask a question, Make a Request, Voice a Concern, Use your Chain of command.
The Sharp End represents where care is delivered, indicating that flawed processes can lead good people to make bad mistakes.
To anticipate and plan for safety, quality, or service issues that may occur within the next 24 hours.
To check the information with an independent, expert source.
By respecting patient privacy and autonomy, and being accountable to patients, society, and the medical profession.
It illustrates that each defense has holes, which can lead to adverse outcomes if penetrated.
Stage 4 lung cancer.
It identifies who or what is to be handed over.
Brief, Execute, and Debrief.
A different patient later hung himself from the newly installed shower curtain rod and died.
Alpha
Juliet
Zulu
By asking encouraging questions of those who are hesitant.
Types of diagnostic error include missed diagnoses, wrong diagnoses, and delayed diagnoses. Causes can range from cognitive biases to system failures. Clinical scenarios can help identify specific causes and inform strategies for mitigation.
HROs strive to bridge the gap between the blunt end and sharp end by translating high reliability leadership lessons into actionable items for front line leaders.
By respecting patient privacy and autonomy, and being accountable to patients, society, and the medical profession while applying relevant laws and policies.
Recognizing health disparities and understanding the meaning and role of the Triple Aim in health reform.
Count the F’s one time and one time only; do not go back and count them again.
Toddlers ask an average of 497 questions a day; rely on your inner toddler to be safe.
Drove at 80mph and stopped by the police, resulting in a delay.
Active failures or unsafe acts (e.g. slips, lapses, mistakes, and violations) can occur on the part of frontline workers.
Poorly designed environment.
Hotel
That's the range four dash five
To assess if the information makes sense, aligns with expectations, and fits with past experiences.
Communication is not just what you say, but what the other person hears; ensuring accurate understanding is crucial to prevent misunderstandings.
Pre-operative clearance for foot surgery.
If they had voiced their concerns to the physician and escalated the issue, it might have led to a different outcome.
Concise (5 min), Crisp (agenda-driven), and Consistent (same place).
Identifying system errors and implementing potential solutions through a system approach.
They guide end-of-life care decisions.
It highlights what is known to be different or unusual about the situation.
The organization did not provide the people, resources, or oversight to support the process or activity being performed.
Mike
That's one - five
The results of the CT scan were not communicated to the primary care physician, and no CT was ordered.
The AHRQ’s CANDOR processes.
Reporting on issues identified on previous days and what is being done to resolve them.
Introduction and Basic Principles, Principles of Improvement Science, Measurement, Metrics, and CQI.
It relates to recognizing high value population-based care and addressing health disparities.
Patient or Project, Plan, Purpose of the Plan, Problems, Precautions.
Self-awareness of knowledge, skills, coping mechanisms, and emotional limitations.
Interpreted the flight time of 8am as the check-in time and arrived at the airport two hours late.
If the nurse had used the 5 P's when placing the work order.
Charlie
Lima
Romeo
Yankee
