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.