L3 (system) :
_🔴Why health care is a complex system :
1-diversity of tasks
2-diversity of patients ,clinicians
3-vulnerability of patients
4- variability or lack of regulations
5-increase specialization of health care professionals
_🔴Approches of iatrogenic injury :
1-Traditional (person) approach : الدكتور اللي غلطان
2-Systemm approach : فيه ميت سبب غير الدكتور وده الصح
_🔴Swiss cheese model :
The model shows that a fault in one layer of the system of care is usually not enough to cause an accident. Adverse events usually occur when a number of faults occur in a number of layers
_🔴Reason’s defences :
Layers of multiple defenses to prevent error from reaching patient (ده اللي هيصلح الجبنة )
_ high reliability organization (HRO):
organizations that operate in hazardous conditions but manage to function at a level of hazard that is almost completely “failure free” that is they have very few adverse events(بتشتغل في الظروف الخطيرة بس بتمشي الدنيا من غير مصايب الحمد لله )
_🔴Characteristics of HRO:
1-preoccupation with failure
2-commitment to resilience
3-sensitivity to operations
4-culture of safety in which individuals feel comfortable
L3 (system) :
_🔴Why health care is a complex system :
1-diversity of tasks
2-diversity of patients ,clinicians
3-vulnerability of patients
4- variability or lack of regulations
5-increase specialization of health care professionals
_🔴Approches of iatrogenic injury :
1-Traditional (person) approach : الدكتور اللي غلطان
2-Systemm approach : فيه ميت سبب غير الدكتور وده الصح
_🔴Swiss cheese model :
The model shows that a fault in one layer of the system of care is usually not enough to cause an accident. Adverse events usually occur when a number of faults occur in a number of layers
_🔴Reason’s defences :
Layers of multiple defenses to prevent error from reaching patient (ده اللي هيصلح الجبنة )
_ high reliability organization (HRO):
organizations that operate in hazardous conditions but manage to function at a level of hazard that is almost completely “failure free” that is they have very few adverse events(بتشتغل في الظروف الخطيرة بس بتمشي الدنيا من غير مصايب الحمد لله )
_🔴Characteristics of HRO:
1-preoccupation with failure
2-commitment to resilience
3-sensitivity to operations
4-culture of safety in which individuals feel comfortable