Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 298

Errors and human behaviour cannot be understood in isolation but only in relation to the context in which people are working. Clinical staff are influenced by the nature of the task they are carrying out, the team they work with, their working environment, and the wider organizational context; these are the system factors. The systems in which we work have inbuilt defences and barriers, and it is only when these defences are simultaneously breached that adverse events occur. This concept forms the basis of Reason’s Swiss cheese model, shown in Figure 11.1.

Table 11.4 Examples of some cognitive biases and heuristics that commonly affect clinical reasoning.

Source: Adapted from Redelmeier²⁴.

Name	Definition	Example
Availability heuristic	Making judgements based on cases that spring easily to mind	‘The last time I saw a patient with fever and a headache, it was only flu, so it is likely to be so in this case too’ (actually meningitis)
Anchoring heuristic	Sticking with initial impressions	The confused elderly patient who has a ‘UTI’ on admission (despite a negative MSU), whose severe constipation goes unnoticed
Framing effects	Making a decision based on how the information is presented to you	‘A&E referred this patient with fever and haemoptysis as “pneumonia”, so that is the most likely diagnosis even though the CXR is normal’ (actually a PE)
Blind obedience	Showing undue deference to seniority or technology – ‘they must be right, and I must be wrong’!	‘My consultant said that this patient could go home, so I am going to ignore concerns raised by nursing staff’; ‘The blood results show a normal haemoglobin even though this patient looks clinically anaemic – the blood results must be right’
Premature closure	Being satisfied too easily with an explanation	In a patient with staphylococcal sepsis, assuming the source of sepsis is their cellulitic leg and missing their underlying endocarditis

Figure 11.1 Reason’s Swiss cheese model.

Learning from high‐reliability organizations in other industries that achieve high levels of safety and performance in the face of considerable hazards and operational complexity is an ongoing challenge to improve safety in healthcare. Important characteristics of these organizations are their safety culture and leadership: there is evidence that these are related to some safety measures in healthcare.

Analyses of incidents usually reveal the causes to be a combination of all the factors described above. This can be summarized by ‘the seven‐level framework’,²⁵ which conceptualizes the patient, task and technology, staff, team, working environment, and organizational and institutional environmental factors that influence clinical practice. This is shown in Table 11.5.

Table 11.5 The seven‐level framework.

Source: Adapted from Vincent, et al.²⁵

Factor types	Contributory influencing factor
Patient factors	Condition (complexity and seriousness) Language and communication Personality and social factors
Task and technology factors	Task design and clarity of structure Availability and use of protocols Availability and accuracy of test results Decision‐making aids
Individual (staff) factors	Knowledge and skills Competence Physical and mental health
Team factors	Verbal communication Written communication Supervision and seeking help Team leadership
Work environmental factors	Staffing levels and skills mix Workload and shift patterns Design, availability, and maintenance of equipment Administrative and managerial support Physical environment
Organizational and management factors	Financial resources and constraints Organizational structure Policy, standards and goals Safety culture and priorities
Institutional context factors	Economic and regulatory context National health service executive Links with external organizations