Section 1: Background

Clinical error

Adverse event (AE)

Health care near miss event (HCNM)

Error and AE

Section 1: Recap 1

Epidemiology

Benchmark studies: the Harvard study of medical practice

The Quality in Australian Healthcare Study

Adverse events among out-patients

Adverse events in the NHS – magnitude of the problem

Section 1: Recap 2

Section 1: Summary

Section 2: Classification, medication errors

Types of error

(1) Active errors

(1a) Knowledge-based errors

(1b) Rule-based errors

(1c) Skill-based errors

(2) Latent (systemic) errors

(2a) Errors related to the working environment

(2b) Procedural errors

(3) Violations

Section 2: Recap 1

Section 2: Recap 1 answers

Errors at the assessment and investigation stage

Errors at the management stage

Errors regarding preventative treatments

Other errors

Medication errors

Most common medication errors

Other types of medication errors

Section 2: Recap 2

Section 2: Summary

Section 3: Consequences

Effects of clinical errors on patients

Effects of clinical errors on the clinician or health care team

Effects of clinical errors committed by other staff

Effects of clinical errors on health care organisations

Effects of clinical errors on society

Section 3: Recap 1

Medical negligence

Clinical negligence in the NHS

Factors influencing medical negligence claims

Link between clinical errors and medical negligence

The Harvard study

Section 3: Recap 2

Adverse events related to assessment

Adverse events related to drug treatment

Adverse events related to management

Section 3: Recap 3

Section 3: Summary

Section 4: Error management

Why do errors occur?

Risk factors that precipitate errors

Organisational model of accidents

Section 4: Recap 1

A threefold approach to error management

Prevention

Early identification

Mitigation of adverse effects, analysis and learning from mistakes

The ASSIST model

Section 4: Recap 2

Section 4: Summary

Module summary

Module test

Take-home notes

References

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