human factors

what is a medication error?

A medication error is a preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is being prescribed, dispensed, prepared, administered or providing advice

What is human factors?

Refer to enhancing clinical preformance through understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and the application to clinical preformance

cognition

• skills-based (automatic mode) - inattention bias

• rule based (problem solving mode) - rules, pattern matching, confirmation bias

• knowlege based - analysis synthesis

what can cause errors?

• system and human errors

• mental workload

• staffing levels

• physical demands - tiredness, hunger and stress

• distractions and interruptions

• physical working environment - clutter, overstocking/lack of stock

• device or product design

what’s in place to help us avoid errors?

• policies and guidelines

• independent checking

• 6 R’s

• BNF and monographs

• labelling of medication - tall man lettering

• compatible syringes

• training and education

• electronic prescribing - flagging drug interactions, allergies and default frequencies and closes

what does the NMC code say?

• only advise, prescribe, supply or administer medicines within your training, the law and relevant agencies

• ensure you know well enough and are confident the treatment meets their health needs

never events - medication

• Mis-selection of strong  potassium solution

• Administration of medication by the wrong route

• Overdose of insulin due to abbreviations or incorrect device use

• Overdose of methotrexate for non-cancer treatment

• Mis-selection of high-strength midazolam during  conscious sedation

never events - administration of medication - wrong route

• Intravenous chemo by the intrathecal route

• Oral/enteral medication or feed/flush by parenteral route

• Intravenous administration of epidural medication that was not intended to be administered by the intravenous route

never events - overdose of insulin due to abbreviations or incorrect device

• The patient received a 10-fold or greater overdose because the term "units" or "international units" was abbreviated (e.g., "U" or "IU"). This error occurred in a care setting that used an electronic prescribing system.

• A healthcare professional fails to use a specific insulin administration device

• A healthcare professional withdraws insulin from insulin pen or pen refill and then administers this is using syringe and needle

near miss

An event that could have led to an error or adverse event but was intercepted or prevented before it caused harm to the patient.

Reviewing near misses can be useful learning and highlight areas for improvement.

what to do if something goes wrong?

• monitor side effects

• inform doctors

• incident report

• duty of candour

duty of candour

general duty to be open and transparent with people receiving care - both statutory and professional

key principles of duty of candour

1.  Act in an open and transparent way with relevant persons about the care and treatment provided.

2. Tell them in person as soon as possible after finding out about the incident. Support them around the incident, including when you tell them what happened.

3.  Provide an accurate account of what happened. This must include all the facts, to the best of your knowledge, at the time.

4.  Tell them in person what further enquiries you will need to make.

5.  Offer an apology in person.

6.  Follow this by giving the same information in writing. Give an update on the enquiries.

7. Keep a written record of all communication with the relevant person.

saying sorry - why important?

• Always the right thing to do

• Not an admission of liability

• Acknowledges that something could have gone better

• The first step to learning from what happened and preventing it recurring

positive safety culture

• education and training

• supporting staff who have made mistakes

• looking at policies and documents such as the NHS patient safety strategy, human factors in healthcare and the health and safety investigation branch