20 th and 22 nd September 2011
description
Transcript of 20 th and 22 nd September 2011
![Page 1: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/1.jpg)
20th and 22nd September 2011
RISCPatient Safety
![Page 2: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/2.jpg)
Facilitators◦ Adam Figgins◦ Adrian Hayes◦ Rosalind Pool◦ Siobhan Reilly◦ Poppy Roberts
◦ Chris Roughley◦ Tommy Salter◦ Jessica Scott◦ Sarah Watson◦ Rebecca Woodside
Acknowledgements
• Dr Vinod Patel, WMS• Institute for Applied Teaching and Learning
![Page 3: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/3.jpg)
7:00 – 7:30 Introduction 7:30 – 7:45 Station 1 7:45 – 8:00 Station 2 8:00 – 8:30 Refreshments 8:30 – 8:45 Station 3 8:45 – 9:00 Station 4
Plan
![Page 4: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/4.jpg)
Consent Form Questionnaires
◦ Before and After Interviews Follow-up
Please complete Before questionnaires now
Evaluation
![Page 5: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/5.jpg)
The freedom from accidental injury due to medical care or from medical error (Institute of Medicine 2000)
‘doing the right thing to the right person at the right time, getting it right first time’(Ambrose, 2009)
What is Patient Safety?
![Page 6: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/6.jpg)
“If you fly on a plane, you have a one in 10m chance of being killed.
If you go into hospital, you have a one in 300 chance – and not from the illness you went in with.”
Richard Branson
Hospitals are Hazardous
![Page 7: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/7.jpg)
1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000
10,000,000
Number of encounters for each fatality
Tota
l liv
es lo
st p
er y
ear
REGULATEDHAZARDOUS(>1/1000)
ULTRA-SAFE(<1/100K)
Health Care
Mountain Climbing
Bungee Jumping
Driving
Chemical Manufacturing
Chartered Flights
Scheduled Airlines
European Railroads
Nuclear Power
Hospitals are Hazardous
Amalberti et al, 2005
![Page 8: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/8.jpg)
Why?
◦Heavy workload◦Fatigue◦Stress◦Shift work◦Reliance on memory◦Reliance on vigilance◦Noise◦Distractions◦Unnatural workflow
Everyone Makes Mistakes
Watson, 2010
![Page 9: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/9.jpg)
Swiss Cheese Model
Reason, 2000
![Page 10: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/10.jpg)
Medical Error
![Page 11: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/11.jpg)
Medical Error
![Page 12: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/12.jpg)
Medical Error
![Page 14: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/14.jpg)
Patient Safety Solutions
![Page 15: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/15.jpg)
Protocols and checklists Constraints Forcing functions Encouraging function Discouraging functions
Leadership and Culture
Patient Safety Solutions
![Page 16: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/16.jpg)
![Page 17: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/17.jpg)
Recommendations◦ BMA◦ GMC◦ WHO
Little formal teachingWalton et al, 2010
RISC initiative
Medical Curriculum
![Page 18: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/18.jpg)
How to prepare for surgery
How to hand over a patient
How to recognise an ill patient, and what to do about it
How to spot an unsafe clinical event, and what to do about it
CHiPS Stations
![Page 19: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/19.jpg)
3rd and 4th year students 3 grants 1 publication (in press) 17 projects
◦ Handover◦ ED Admissions◦ Sepsis◦ Medication Error Audits◦ Surgical Safety Checklist◦ iPhone App◦ Uniforms for Medical Students
RISCPatient Safety
Get Involved!
![Page 20: 20 th and 22 nd September 2011](https://reader031.fdocuments.us/reader031/viewer/2022020106/56815e5d550346895dccd575/html5/thumbnails/20.jpg)
Patient safety is important (and interesting)
Medical students can contribute
Conclusion