Patient Safety and Duty of Candour

Module Learning Outcomes

• Evaluate potential hazards and errors in cross-sectional imaging, including:
  • System failures
  • Human errors
• Importance of effective communication:
  • Ensures informed patient consent
  • Communicating risks associated with imaging to patients and healthcare teams

Session Outcomes

• Understand the reporting of incidents and learning from them
• Recognize hazards and mistakes specific to CT imaging
• Identify communication pitfalls in incidents
• Importance of proactive safety reviews
• Familiarity with SIEPS (System Engineering Initiative for Patient Safety) and PSIRF (Patient Safety Incident Reporting Framework)
• Define Duty of Candour and its significance

Causes of Mistakes

• Multiple contributing factors:
  • Physical: Tiredness, stress, and urgent workloads
  • Psychological: Mental health issues (e.g., anxiety, depression)
  • Organizational: Poor leadership and inadequate training
• Rarely intentional; primarily arise from compounding stressors

Human Factors Defined

• The impact of human behavior on safety, including:
  • Teamwork dynamics
  • Interaction with technology
  • Work environment and organizational culture
• Human factors ergonomics: Focuses on designing safe work systems to mitigate errors
• Risk increase: Higher fatigue, stress, and poor hydration contribute to errors

Swiss Cheese Model

• Systems and protocols are built like Swiss cheese, with inherent flaws.
• Alignment of flaws in different systems can lead to incidents.
• Focus on preventing alignment of these flaws to ensure safety.

Incident Reporting and Investigations

• Report incidents via a designated electronic system for accountability.
• Timeliness is crucial; aim for reporting within 24 hours.
• Approach should focus on learning from incidents, not assigning blame:
  • Emphasize a no blame culture for transparency and improvement.

Importance of Feedback

• Without feedback, there's less incentive to report incidents.
• Teams must know the outcomes and improvements resulting from reported incidents.

Characteristics of Good Communication in Incidents

• Avoid assumptions and misinterpretations.
• Clarifying questions are vital.
• Define roles clearly before executing tasks.
• Use clear, unambiguous language and ensure accurate documentation in patient records.

Good Safety Culture

• Proactive reviews: Regularly assess systems to identify and correct potential errors before they occur.
• Foster an open and safe environment for discussing mistakes and facilitating feedback.

Embedding Safety into Practice

• Maintain a pace aligned with skills and knowledge.
• Encourage seeking help when uncertain or unsafe.
• Prioritize communication and raise concerns about inadequate systems.

PSIRF Overview

• Aims: Insight, involvement, and improvement in patient safety.
• Focuses on systemic issues rather than individual mistakes.
• Emphasizes learning from all incidents, including low or no harm.

Key Points of SEIPS

• A system for understanding how workflow impacts patient safety.
• Facilitates comprehensive problem-solving by examining all work system factors interacting in incidents.