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Poor organisational design is presented as setting people up to fail, so the focus shifts to changing the system to improve safety.",{"name":70,"@type":61,"acceptedAnswer":71},"What human factors and behaviour reasons are used to explain why errors occur?",{"text":72,"@type":64},"The notes highlight factors such as fatigue and sleep deprivation, inadequate nutrition and hydration, overload, and training and experience. It also emphasizes that there are good reasons people behave as they do, and understanding those reasons helps explain how errors occur in the system.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},243840,1791747238,{"code":4,"msg":82,"data":83},"success",[84,88,93,98,103,108,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":86,"slug":87},11,90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":110,"show_sort_weight":111,"slug":112},17,"Forms",40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":85,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":136,"language":137,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":12,"update_tm":141,"read_time":55},1374402968488,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Root Cause Analysis  \nLiverpool Heart and Chest Hospital  \n2016  \nCourse Aims  \n􀂄 To provide/improve  \n1. Understanding of theory underpinning RCA  \n2. Skills to undertake effective RCA  \n3. Tools to undertake RCA analysis  \n4. Understanding of the advantages of a ‘systems’based approach.  \n5. Develop an appreciation of the correct way to writeup an investigation report  \nWHY?  \nTo learn and share lessons  \nCosts  \n􀂄 Costs to the NHS healthcare system  \n-adverse events cost £1 billion/yr in hospital stay alone  \n- > £400 million clinical negligence settlements/year  \nCosts to our patients  \n-can have a life long affect on the quality of life for patients  \nImpact on  \nStaff  \n􀂄 It has been estimated that 38% of doctors who are subject of a clinical negligence claim suffer clinical depression as a result of the process…there is damage to a doctor’s reputation, morale, self-esteem and professional confidence.  \nCMO making Amends DOH 2003  \n􀂄 I am so afraid of making another mistake. I want to give it all up and work in Tesco where the worst mistake I could possibly make will only be to annoy somebody, not kill them.  \nAnon (Registered Nurse)  \nUnderstanding causes  \nadverse incident  \nPerson centred approach  \n􀂄 Individuals who make errors are ‘careless, at fault, reckless’  \n􀂄 Blame and punish  \n􀂄 Remove individual=improve safety  \nSystems approach  \n􀂄 Poor organisational design sets people up to fail  \n􀂄 Focus on the system rather than the individual  \n􀂄 Change the system=improve safety  \nHuman Error  \n􀂄 We all make errors irrespective of how much training and experience we possessor how motivated weare to do it right  \nReducing and influencing behaviour-HSG48  \n􀂄 There are good reasons why we behave as we do  \n􀂄 If we understand those reasons we can understand why errors have occurred in the system  \nHuman Factors  \nThe study of how humans behave physically and psychologically in relation to particular environments, people or procedures  \nOther Human Factors  \n􀂄 Fatigue, sleep deprivation  \n􀂄 Inadequate nutrition,hydration  \n􀂄 Overload  \n􀂄 Training and experience  \n􀂄 Team dynamic  \nRasmussens Skill, Rule and  Knowledge Model  \n􀂄 Knowledged Based  \nConscious thought required  \nUnskilled or occasional user  \nNew environment  \nEffortful Slow  \nLack of awareness of consequences  \n􀂄 Skill Basedautomatic  \n􀂄 Skilled regular use  \n􀂄 Familiar environment  \n􀂄 Effortless  \n􀂄 Fast  \n􀂄 Strong habit focus  \nError Types  \nIntended Actions  \nRoutine violations-regular short cuts accepted by clinical  \nteam because procedure badly designed Reasoned violations – occasional change from  \nprocedure with good intent i.e. emergency situation Reckless violations – unacceptable changes from  \nprocedure. Harm is likely but not intended Malicious violations – deliberate acts intended to cause  \nharm","cbCainhp2Yu6QqYU","https://ap.wps.com/l/cbCainhp2Yu6QqYU","pdf",939814,36,"English","# Course Aims\n# WHY and Costs\n# Impact on Staff and Patients\n# Understanding Causes\n## Person-centred and Systems approach\n## Human error and human factors\n# Rasmussen’s Skill-Rule-Knowledge Model\n## Error types and violations","[{\"question\":\"What are the learning aims of the Root Cause Analysis course?\",\"answer\":\"The course aims to improve understanding of RCA theory, build skills to undertake effective RCA, introduce RCA tools, explain benefits of a systems-based approach, and develop the ability to write an investigation report correctly.\"},{\"question\":\"How does the material explain the difference between blame and a systems approach?\",\"answer\":\"Individuals making errors should not simply be blamed or punished; removing individual blame improves safety. 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