Professional Documents
Culture Documents
Safety
How You Can Improve the
Safety of Patient Care
Traditional Methods of
Protecting Patients From
Harm
Well structured systems
Explicit processes
Professional standards of
practice
Inattention
Memory lapse
Failure to communicate
Poorly designed equipment
Exhaustion
Ignorance
Noisy working conditions
A number of other personal and
environmental factors
ERROR TYPES
Basic error types
Routine
Reasoned
Reckless & Malicious
Violations
Rule & Knowledge
Based errors
Intended
actions
Mistakes
Unsafe
Unsafe
acts
acts
Lapses
Unintended
actions
Slips
Process Redesign
Solutions
Process Redesign
Solutions
Process Redesign
Solutions
Human interventions
Response teams
Backups
Automation
Example
Where to Start
Common Causes of
Medication Related
Lack of staff orientation/training
Sentinel
Events
Communication failure
Proactive Safety
Improvement
FMECA Steps
A Strategic Objective