Learning from errors to prevent harm
Topic
5
Learning
from
error
s
to
preven
t
harm
Pati
en
t
Safety
Cur
ric
ulum
Guide
1
Learning
objecti
v
e
Pati
en
t
Safety
Cur
ric
ulum
Guide
2
Unde
r
sta
n
d
the
n
atu
r
e
o
f
err
o
r
a
n
d
how
h
ea
l
t
h
-
care
p
r
o
v
id
e
r
s
ca
n
l
e
arn
f
r
om
e
r
r
o
r
s
to
imp
r
o
v
e
p
a
ti
e
n
t
safe
t
y
Knowledge
requirement
Pati
en
t
Safety
Cur
ric
ulum
Guide
3
Expl
a
i
n
t
h
e
t
e
rm
s:
Erro
r
Viola
ti
o
n
Nea
r
mi
s
s
Hind
s
ig
h
t
b
i
as
Perfor
m
a
n
ce
req
u
irem
e
nts:
Pati
en
t
Safety
Cur
ric
ulum
Guide
4
Know
the
wa
y
s
to
le
a
rn
fro
m
e
r
r
ors
Parti
c
ip
ate
i
n
t
h
e
a
na
l
y
s
is
o
f
a
n
a
d
v
er
s
e
event
Pra
ctis
e
st
r
at
e
g
i
e
s
to
r
e
d
uce
e
r
r
ors
Error
Pati
en
t
Safety
Cur
ric
ulum
Guide
5
A
s
imple
definitio
n
is:
“Doing
the
w
ro
n
g
th
i
ng
when meani
n
g
to
do
the
right
th
i
n
g
.”
Bi
l
l
Runciman
A
m
o
re
for
m
al
definitio
n
is:
“Planned
s
eque
n
ces of
mental or
p
h
ysical activi
t
ies
tha
t
fa
i
l
t
o
achieve
t
h
ei
r
in
t
ende
d
o
u
tcomes
,
when
thes
e
f
ail
ure
s
can
n
ot
be
attributed
t
o
the
intervention
of
some
chance agency.”
Jam
e
s
Reas
on
Note
:
violation
Pati
en
t
Safety
Cur
ric
ulum
Guide
6
A
d
elib
e
r
ate
d
ev
i
at
i
o
n
f
r
om
a
n
a
c
ce
pt
e
d
p
r
ot
o
co
l
o
r
s
tan
d
ard
o
f
care
Errors
an
d
ou
t
comes
Pati
en
t
Safety
Cur
ric
ulum
Guide
7
Errors
a
n
d
o
u
tcomes
ar
e
n
o
t
i
n
e
x
tr
ic
a
b
l
y
l
i
nk
e
d:
•
H
a
rm
can
befal
l
a
patie
nt
i
n
the
form
o
f
a
compl
i
cation
o
f
c
a
re
w
itho
ut
a
n
er
r
o
r
h
avi
n
g
occurred
•
Many
e
rrors
occu
r
tha
t
hav
e
n
o
cons
e
qu
e
nce
for
the
p
atie
nt
a
s
the
y
ar
e
r
eco
g
niz
e
d
before
har
m
occurs
Hum
a
n
factors
princip
l
es
remi
n
d
u
s
that:
Pati
en
t
Safety
Cur
ric
ulum
Guide
8
Error
i
s
the
i
nev
i
table
do
w
nsi
d
e
o
f
h
avi
n
g
a
brain!
One defin
i
tion
of “human error”
i
s
“
human nature”
Hum
a
n
bei
n
g
s
make
mistakes
Pati
en
t
Safety
Cur
ric
ulum
Guide
9
R
e
gard
l
es
s
o
f
the
i
r
e
x
peri
e
nce
,
i
n
tel
l
i
g
enc
e,
mot
iv
a
tion
o
r
v
i
gi
l
anc
e,
pe
o
pl
e
make
m
istakes
A
c
t
i
v
i
t
y
:
Th
i
n
k
ab
o
u
t
an
d
then
disc
u
ss
w
ith
your
col
l
ea
g
ues
any “sil
l
y
mistakes
”
you
hav
e
m
ad
e
r
ece
n
tly
w
h
en
you
w
e
re
no
t
i
n
your
pl
a
ce
o
f
w
or
k
o
r
study
-
an
d
w
h
y
you
think
they
happe
n
ed
The
healt
h
-care
context
i
s
problem
a
tic
Pati
en
t
Safety
Cur
ric
ulum
Guide
10
When
er
r
or
s
o
ccur
i
n
the
w
o
rkplace
the
cons
e
qu
e
nces
can be a probl
e
m
for the
p
atie
n
t…
…. a situation
that is relatively uni
q
ue
to health
care
I
n
al
l
othe
r
r
esp
e
cts
there
i
s
nothin
g
un
i
qu
e
ab
o
ut
“hea
l
th-care”
errors…
.
.
.
they
ar
e
n
o
d
i
f
f
eren
t
fr
o
m
the
hum
a
n
factors
prob
l
em
s
that
e
x
is
t
i
n
settings
outsid
e
he
a
lt
h
care
S
o
urc
e
:
J.
R
e
as
o
n
E
r
r
o
r
s
Skil
l
-
ba
s
e
d
slips
an
d
lap
s
es
A
t
ten
t
iona
l
slips
o
f
a
c
tion
Lap
s
e
s
of
memory
R
u
l
e-
ba
s
ed
mistak
es
Knowled
g
e
-
ba
s
e
d
mistak
es
Mi
s
ta
k
es
…
…
…
…
Pati
en
t
Safety
Cur
ric
ulum
Guide
11
Summary
o
f
the
princip
a
l
erro
r
types
Situations
associate
d
wit
h
an
incr
e
ase
d
risk
o
f
err
o
r
Pati
en
t
Safety
Cur
ric
ulum
Guide
12
Ine
x
p
e
rie
n
ce*
Time
pressures
Inadeq
u
at
e
check
i
ng
P
o
o
r
proce
d
ures
Inadeq
u
at
e
i
n
for
m
ation
*
E
s
p
e
c
i
a
l
l
y
i
f
c
o
m
b
i
n
e
d
w
i
t
h
l
a
c
k
o
f
s
u
p
e
r
v
i
s
i
o
n
Individ
ua
l
factors
t
hat
predispos
e
to
error
Pati
en
t
Safety
Cur
ric
ulum
Guide
13
Limite
d
mem
or
y
ca
p
acity
Further
reduced
by:
•
fatig
u
e
•
st
ress
•
hunger
•
i
l
l
n
ess
•
l
a
ng
u
ag
e
o
r
cultur
a
l
fact
ors
•
haz
a
rdous
at
titud
e
s
Don
’
t
forget
….
Pati
en
t
Safety
Cur
ric
ulum
Guide
14
If
yo
u
’re
•
H
u
n
g
r
y
•
A
n
g
r
y
•
L
a
t
e
•
T
i
r
e
d
…
.
.
or
H
A
L
T
A
performanc
e
-shap
i
ng
factors
“checklist”
Pati
en
t
Safety
Cur
ric
ulum
Guide
15
I
I
l
l
n
e
s
s
M
M
e
d
i
c
a
t
i
o
n
:
p
r
e
s
c
r
i
p
t
i
o
n
,
o
v
e
r
-
t
h
e
-
c
o
u
n
t
e
r
a
n
d
others
S
A
F
E
S
t
ress
Alcohol
Fa
t
igue
Emo
t
ion
A
m
I
s
a
f
e
t
o
w
o
r
k
t
o
d
a
y
?
Incident
reporting/monitoring
Pati
en
t
Safety
Cur
ric
ulum
Guide
16
Involves
collecting
an
d
an
a
lyzin
g
infor
m
ation
ab
o
ut
a
ny
ev
e
n
t
that
could
h
ave
harme
d
o
r
did
har
m
a
nyone
in
th
e
o
rga
n
ization
A
fu
n
damen
t
al
compon
e
nt
of
an
orga
nization’s
ability
to
lear
n
from
error
Rem
o
ving
erro
r
traps
Pati
en
t
Safety
Cur
ric
ulum
Guide
17
A
primar
y
fu
n
ction
o
f
a
n
incid
e
n
t
reporting
system
is
to
ide
ntify
rec
urr
in
g
pro
b
le
m
are
a
s
-
kno
w
n
a
s
“
error
traps
”
(
J
.
Reaso
n
)
I
d
entifyi
n
g
an
d
removing
th
es
e
trap
s
is
o
ne
o
f
the
main
functions
o
f
er
ro
r
manag
e
ment
M
odif
i
ed
f
r
om
R
.
Cook,
2005
,
A
B
rief
Look
at
the
New
Look
in
Co
m
plex
Sy
s
tem
F
ailu
r
e,
E
r
r
o
r
,
Safety
and
R
e
s
ilie
n
ce
Befo
r
e
the
Inc
i
dent
After
the
Inc
i
dent
Hin
d
sig
h
t
Bi
a
s
Pati
en
t
Safety
Cur
ric
ulum
Guide
18
Culture
:
a
workabl
e
definition
'
S
har
ed
v
alu
e
s
(what
i
s
im
p
ort
ant)
and
bel
ie
f
s
(h
ow
thin
gs
work
)
t
hat
inte
r
act
with
an o
r
ga
n
izatio
n
’
s
struct
u
r
e
and
con
t
r
ol
system
s
t
o
produ
c
e
behavio
u
r
al
norms
(t
h
e
w
a
y
w
e
do
thi
n
gs
a
r
ou
n
d
he
r
e)'
J
a
m
e
s
R
e
a
s
on
Pati
en
t
Safety
Cur
ric
ulum
Guide
19
Cultur
e
i
n
the
wor
kplace
Pati
en
t
Safety
Cur
ric
ulum
Guide
20
It
is
h
a
rd
to
“cha
n
ge
the
world”
as
a
junior
h
ealt
h
-care
prof
e
ssion
al
But
…
…you
can
be
on
th
e
lo
ok
out
f
or
ways
to
improve
the
“system”
…
you
c
a
n
co
ntribute
to
the
culture
in
yo
ur
work
e
nvironment
Inc
iden
t
reporting
an
d
moni
t
oring
s
t
rategies
Pati
en
t
Safety
Cur
ric
ulum
Guide
21
S
u
cce
s
sful
stra
t
e
g
i
e
s
in
c
l
u
d
e
:
•
an
o
nymou
s
reporting
•
timely
fee
d
back
•
op
e
n
ackno
w
l
e
dg
e
ment
o
f
s
u
ccesses
resulti
n
g
f
rom
i
n
ci
d
e
n
t
reporti
n
g
•
reporting
o
f
n
ea
r
m
iss
e
s
-
“
f
ree"
l
e
ssons
can
be
l
e
arned
-
syste
m
improvement
s
ca
n
b
e
i
n
stitu
t
e
d
a
s
a
result
o
f
the
i
n
vesti
g
ation
but
at
no
“cost” to
a pat
i
ent
Sour
c
e
:
E
.
B.
Lar
s
on
Roo
t
cause
analysi
s
(RCA)
Pati
en
t
Safety
Cur
ric
ulum
Guide
22
A
st
ructure
d
ap
p
roch
to
i
n
ci
d
en
t
an
a
lys
i
s
Estab
l
is
h
e
d
b
y
the
Nation
a
l
C
e
nte
r
for
P
a
tient
Safety
of
the
U
S
D
e
p
a
r
t
ment
o
f
V
eteran
s
Affairs
h
tt
p
:
//
www
.
v
a
.
go
v
/
NC
PS/c
urri
c
ulu
m
/
RC
A/
in
d
e
x
.
h
tm
l
RC
A
model
(
1
)
Pati
en
t
Safety
Cur
ric
ulum
Guide
23
A
rigorous,
confidenti
a
l
ap
p
roach
to
a
nsw
e
ring:
What
h
a
pp
e
ne
d
?
Who
wa
s
i
n
vo
l
ved?
When
di
d
i
t
ha
p
pe
n
?
Wh
e
re
di
d
i
t
h
a
p
p
e
n
?
H
o
w
severe
w
a
s
th
e
actua
l
o
r
p
otentia
l
harm?
What
i
s
th
e
l
i
ke
l
i
h
o
od
o
f
recurrence?
What
w
er
e
th
e
cons
e
qu
e
nces?
RC
A
mod
e
l
(2)
F
o
cus
e
s
o
n
prev
e
nti
o
n
,
no
t
bl
a
me
o
r
p
u
n
i
shme
n
t
Foc
u
ses
o
n
system
l
e
vel
vu
l
nerab
i
l
i
ties
rather
th
a
n
i
n
div
i
du
a
l
perfo
r
mance
It
e
x
ami
n
e
s
mult
i
p
l
e
factors
such
as:
Pati
en
t
Safety
Cur
ric
ulum
Guide
24
-
comm
un
i
cation
-
t
rai
n
i
n
g
-
fatig
u
e/sch
e
d
u
l
i
ng
-
env
i
ronment
/
eq
u
i
p
ment
-
rules/po
l
ic
i
es/proce
d
ures
-
b
a
rr
i
e
rs
Personal
error
reducti
o
n
strategies
Pati
en
t
Safety
Cur
ric
ulum
Guide
25
K
n
o
w
yourse
lf:
ea
t
w
el
l
,
sl
e
e
p
w
e
l
l,
l
o
o
k
af
te
r
yourse
lf
K
n
o
w
your
environment
K
n
o
w
your
task(s)
Prep
a
ration
an
d
pla
n
ni
n
g
;
“What
if
…
?”
B
u
i
l
d
“check
s
”
i
n
to your
routi
n
e
A
s
k
i
f
y
o
u
d
o
n
’
t
k
n
o
w
!
Mental
prepared
n
ess
Pati
en
t
Safety
Cur
ric
ulum
Guide
26
Assume
th
a
t
error
s
can
a
n
d
w
il
l
occur
I
de
ntify
those
circu
m
stances
most
likely
to
breed
error
Hav
e
co
nting
e
ncies
in
p
lac
e
to
c
o
p
e
wit
h
p
roblems,
int
e
rruptio
n
s
a
n
d
distractio
n
s
Me
ntally
re
h
e
arse
complex
proc
e
d
ures
J
a
m
e
s
Rea
s
on
Summary
Pati
en
t
Safety
Cur
ric
ulum
Guide
27
H
e
a
lth-
c
a
r
e
err
or
i
s
a
comp
l
e
x
iss
u
e
,
bu
t
err
or
itse
l
f
i
s
an
i
n
ev
ita
b
l
e
par
t
o
f
the
hum
a
n
co
n
d
ition
Le
a
rni
n
g
from
err
or
i
s
more
pro
d
u
cti
v
e
i
f
i
t
i
s
cons
i
der
e
d
at
a
n
org
a
n
iza
t
io
n
a
l
l
e
v
el
R
o
o
t
cause
an
a
lys
i
s
i
s
a
hi
g
h
ly
structured
system
approac
h
to
inc
i
de
n
t
ana
l
ysis
Delve into the realm of patient safety to understand and prevent harm by learning from errors. Explore the nature of errors, definitions, human factors, and more to enhance healthcare practices.
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Presentation Transcript
Topic5 Learning from errors to prevent harm Patient Safety Curriculum Guide 1
Learning objective Understand the nature of error and how health- care providers can learn from errors to improve patient safety Patient Safety Curriculum Guide 2
Knowledge requirement Explain the terms: Error Violation Near miss Hindsight bias Patient Safety Curriculum Guide 3
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
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
Note: violation A deliberate deviation from an accepted protocol or standard of care Patient Safety Curriculum Guide 6
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
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
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
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
Summary of the principal error types Attentional slips of action Skill-based slips and lapses Lapses of memory Errors Rule-based mistakes Mistakes Knowledge- based mistakes Source: J. Reason Patient Safety Curriculum Guide 11
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
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
Dont forget . If you re Hungry Angry Late Tired .. H A L T or Patient Safety Curriculum Guide 14
A performance-shaping factors checklist I Illness M others S A F E Emotion Medication:prescription, over-the-counter and Stress Alcohol Fatigue Am I safe to work today? Patient Safety Curriculum Guide 15
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
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
Hindsight Bias Before the Incident Afterthe Incident Modifiedfrom R. Cook, 2005,ABrief Look at the New Look in Complex System Failure, Error , Safety and Resilience Patient Safety Curriculum Guide 18
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
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
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
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
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
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 - training - fatigue/scheduling - environment/equipment - rules/policies/procedures - barriers Patient Safety Curriculum Guide 24
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
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
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
