Medicines Safety

What is the LFPSES?

Learning from patient safety events

What are benefits of LFPSES?

Easier to report
High quality data
Can use machine learning in analysis

What is good practice with errors?

be honest with patients if something goes wrong

• What happened

• Apologise

• Offer remedy and support

• Explain short and long-term effects

What is the legality around duty of candour?

Legally required if potential harm more than ‘significant’

What does official duty of candour involve?

• Information about pending investigation

• A letter of apology confirming investigation terms of reference

• Contact details for updates

• Offer to meet patient to discuss findings

Define a never event?

Serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations”

What are the current never events?

• Mis-selection of a strong potassium solution

• Administration of medication by the wrong route

• Overdose of insulin due to abbreviations or incorrect device

• Overdose of methotrexate for non-cancer treatment

• Mis-selection of high strength midazolam during conscious sedation

Why has it been suggested some of the never events be removed off the list?

They do not have ‘strong and systemic barriers’

Define safety 1 approach?

As few things as possible go wrong

Describe the safety 1 process?

• Accidents result from special mechanisms

  • A chain of events leading to harm

  • Different from the mechanisms active during ‘ordinary work’

• Making clearly defined interventions can break the chain and prevent harm

  • Rules, guidelines, technology etc

• By recording harm, we can learn from it and prevent it

• Can prevent a limited set of common harms

• But overly simplistic

Define safety 2 approach?

As many things as possible go right

Describe the safety 2 process?

• Accidents have no special causes

  • Result from the same mechanisms as ‘normal work’

• Interventions aim to make:

  • Risks and consequences more obvious

  • Actions more easily reversible

  • Enhance workers’ ability to respond effectively

How do the safety theories see safety?

• Safety 1 sees safety as a property of the system

• Safety 2 sees safety as an activity of staff

Describe non linear safety models?

• ‘errors’ and defects will be abundant and ubiquitous

  • will interact to produce a catastrophic incident

• need safe systems, but may not work day to day

• staff need skills to identify risk and adapt their environment

• how risk resilient the system is and how to enhance this

What do safety 2 interventions allow?

• Facilitate everyday work – make it easy for staff to do things safely

• Anticipate developments and events

• Maintain and develop the ‘adaptive capacity’ to respond effectively to the inevitable surprise

Why is healthcare dominated by safety 1?

• Health professionals are trained in physical sciences, so tend to feel more comfortable with Safety 1 thinking

• Threat rigidity: under Safety 1, after an incident the logical thing is to tighten the rules

Why does safety 2 oppose incident reporting?

• are rare

• only reflect single moments in time, rather than the system’s ability to manage risk

• minority (<1%) of incidents are reported

  • Can’t calculate incident rates

• Not useful unless adequate resources to follow up

• lack the narrative needed for learning

Why does safety 2 never events?

• unobtainable goal - some errors will always happen

• Unintended consequences as people try to meet unobtainable target

  • Frustrating and demoralising for staff à burnout

  • Hide events → less learning and improvement

  • Blame and bullying

  • Opportunity cost

  • Cultivates cynicism

Define a safety cluster?

The accumulation of safety procedures, documents, roles and activities that are performed in the name of safety, but do not contribute to the safety of operation

What does hindsight bias do to error?

tendency to perceive past events as having been more predictable than they were

What are stronger actions?

Engineering controls (forcing functions)
Simplify the process

What are intermediate actions?

Redundancy
Software modification

What are weaker actions?

Double checks
New procedure/reminder
Training