Patient safety and quality

Ten times the dose

• (Fictional) A nurse at the bedside notices that a syringe holds ten times the prescribed dose and stops. Nobody is harmed. Whose fault was it?
• Patient safety asks a better question: which parts of the system let the error travel that far? This lesson is about errors as system failures.

The Swiss cheese model

• In Reason's Swiss cheese model 瑞士奶酪模型, a hazard meets several layers of defence: design, barriers, procedures, people. Every layer has holes.
• Harm happens only when the holes in all the layers line up. So the question after an incident is what made the holes, not who was standing in one.

Analysing an incident

• After an incident, memory builds a tidy story with one person to blame. A structured method searches every layer instead.
• The London Protocol checks seven groups of contributing factors: patient, task and technology, individual staff, team, work environment, organisation and management, and institutional context.

Near-misses are free lessons

• A near-miss 未遂事件 is an error caught before it causes harm. It shows exactly where the holes are, at no cost to a patient.
• Reporting near-misses keeps the holes visible. A culture where staff can speak up without fear is itself a layer of defence.

SBAR for handovers

• Information gets lost when care passes between people. The SBAR handover SBAR 交接 fixes the order: Situation, Background, Assessment, Recommendation.
• At the bedside, the same idea gives the "five rights" check: right patient, drug, dose, route and time.

Measuring quality

• Judge a service on three levels: structure (staff, equipment), process (were the right steps done, such as checklists and handovers) and outcome (results for patients, adjusted for risk).
• Process measures respond quickly to improvement work; outcome measures show whether patients actually benefit. Quality work tracks both.

Common slips

Recap