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