--- module: 073-01 language: en chapter: 73 title: "Patient Safety, Quality Improvement, Human Factors, and Clinical Systems" module_title: "Error and harm, human performance, communication, deterioration, and safety culture" source_sha256: c0947ecb4503ce082797bcb2eed50a0c90b5fde0ea8f21e7bceb27a002ad4856 --- # Foundations of patient safety ## What patient safety studies ### How care causes preventable harm ### Make correct action easy, error visible, recovery possible ### Harm from interacting system factors #### People, tasks, technology, environment, organisation, patient ### Blame without system learning leaves hazards ## Error, violation, and harm ### Error: failed plan or incorrect plan #### Slip: execution failure in automatic work #### Lapse: memory failure #### Mistake: flawed rule or knowledge decision ### Violation: deliberate departure from a rule #### Routine, situational, exceptional, malicious ### Hazard, near miss, no-harm incident, adverse event #### Adverse event: harm from care, not disease ### Preventability judged against reasonable practice ### Outcome bias: severe result makes action look worse ## Layered defences and latent conditions ### Barriers: training, checks, design, pharmacy, monitoring ### Active failures align with latent conditions #### Understaffing, layout, labelling, software, pressure ### Swiss cheese implies static holes #### Clinicians trade efficiency against thoroughness ### Work-as-imagined differs from work-as-done ### Resilience: anticipate, monitor, respond, learn ### Redundancy can diffuse responsibility ### High reliability principles #### Sensitivity to operations, reluctance to simplify #### Deference to expertise, preoccupation with failure ## Human cognitive performance ### Limited attention and working memory #### Prospective memory fragile during interruptions #### Checklists help when built into workflow ### Automatic processing prone to pattern error ### Expertise can increase anchoring #### Timeouts and second opinions allow reframing ### Naming biases does not prevent them #### Change information flow instead ### Fatigue impairs vigilance and judgement #### Rostering, breaks, supervision over exhortation ## Workload, interruptions, and design ### Stable performance until capacity is exhausted #### Small extra demand, disproportionate failure ### Protect high-risk tasks from interruption #### Provide a reliable way to resume ### Poor usability invites predictable mistakes #### Forcing functions, constraints, affordances #### Training is not the sole remedy ### Accessibility is a safety property ### Alarms must be actionable and specific #### False alarms cause desensitisation and delay ## Communication as a shared mental model ### Fails through ambiguity, hierarchy, no confirmation ### Closed loop: name, state, read back, confirm ### Structured handover does not guarantee understanding #### Distinguish certainty from concern ### Psychological safety to ask and raise risk #### Leaders invite dissent and thank concerns ## High-risk safety domains ### Medication harm across the whole pathway #### Reconciliation and indication-linked prescribing ### Diagnostic error: missed, delayed, wrong, uncommunicated #### Trajectory reveals error later, needs feedback ### Procedural harm: wrong site, retained objects #### Ritualised checks lose meaning ### Infection: bundles work when every element is reliable #### Review device necessity daily ## Deterioration detection and response ### Early-warning scores support, not replace, judgement #### Miss concern, atypical baselines, abrupt change ### Failure to rescue: complication missed or unmanaged #### Normalisation, diffused responsibility, delay ### Families and staff need escalation routes ## Safety culture beyond slogans ### Shown by what leaders resource and tolerate ### Punishment, futility, burden deter reporting ### Just culture separates error, at-risk, reckless, intent ### Burnout is systemic, not an individual defect #### Wellbeing cannot replace safe staffing ### Goal: reliable care that anticipates human limits