INCIDENTS

INCIDENTS

Understanding the concepts underlying patient safety inci - dents is useful because it helps to anticipate situations that are - likely to lead to errors and highlights areas where preventative action can be taken. The problem of error can be view ed in two ways – from a person approach or from a system approach. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Human factors Inadequate patient assessment; delays or errors in diagnosis Failure to use or interpret appropriate tests Error in performance of an operation, treatment or test Inadequate monitoring or follow-up of treatment De /f_i ciencies in training or experience Fatigue, overwork, time pressures Personal or psychological factors (e.g. depression or drug abuse) Patient or working environment variation Lack of recognition of the dangers of medical errors System failures Poor communication between healthcare providers Inadequate staf /f_i ng levels Disconnected reporting systems or over-reliance on automated systems Lack of coordination at handovers Drug similarities Environment design, infrastructure Equipment failure owing to lack of parts or skilled operators Cost-cutting measures by hospitals Poor governance structures and inadequate systems to report and review patient safety incidents Medical complexity Advanced and new technologies Potent drugs, their side effects and interactions Working environments – intensive care, operating theatres

INCIDENTS

Understanding the concepts underlying patient safety inci - dents is useful because it helps to anticipate situations that are - likely to lead to errors and highlights areas where preventative action can be taken. The problem of error can be view ed in two ways – from a person approach or from a system approach. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Human factors Inadequate patient assessment; delays or errors in diagnosis Failure to use or interpret appropriate tests Error in performance of an operation, treatment or test Inadequate monitoring or follow-up of treatment De /f_i ciencies in training or experience Fatigue, overwork, time pressures Personal or psychological factors (e.g. depression or drug abuse) Patient or working environment variation Lack of recognition of the dangers of medical errors System failures Poor communication between healthcare providers Inadequate staf /f_i ng levels Disconnected reporting systems or over-reliance on automated systems Lack of coordination at handovers Drug similarities Environment design, infrastructure Equipment failure owing to lack of parts or skilled operators Cost-cutting measures by hospitals Poor governance structures and inadequate systems to report and review patient safety incidents Medical complexity Advanced and new technologies Potent drugs, their side effects and interactions Working environments – intensive care, operating theatres