1. Human Factors (or Ergonomics)
1.1. Human Factors studies: 1. How people interact within complex systems 2. How people interact with each other in complex systems 3. How problems with those interactions lead to errors and breakdowns in safety
1.1.1. It is important that nurses acknowledge the personal factors impacting their job and their ability to provide quality care e.g Tiredness, nutrition, stress and situational awareness (Brennan & Oeppen, 2022).
1.1.1.1. An example of human factors and ergonomics being acknowledged within a clinical environment was the implementation of electronic beds which improve a nurses ability to maneuvre and interact with a patient, allowing nurses to control the height and posture of the bed, thus improving quality of care for the patient and reducing risk of injury for the nurse (Sousa et al., 2023).
1.2. "Human factors refer to environmental, organisational and job factors, and human and individual characteristics, which influence behaviour at work in a way which can affect health and safety" (Health and Safety Executive, 2021)
1.3. Understanding the impact human factors have on nurses and developing systems with a focus on teamwork and communication within a clinical space has shown to majorly improve the quality and safety of patient care (Keebler et al., 2022)
1.3.1. "Good teamwork is a core aspect of success in a variety of healthcare tasks, with recent meta-analytic evidence suggesting that team training in healthcare organizations can reduce patient mortality by as much as 15%" (Hughes et al., 2016).
2. Understanding Errors
2.1. Types of Errors: 1. Skills-based slips and lapses: These are known as errors of execution and are called slips if the action is observable, or a lapse if it is not. 2. Mistakes: A mistake occurs as a result of a failure of planning (the plan is wrong). These can be ruled based or knowledge based.
2.1.1. Slips and lapses typically occur when an individual (nurse) knows what they want to do, but due to distractions or attentitive failures, the action does not turn out as intended (Higham & Vincent, 2020).
2.1.1.1. Examples include: Slip - accidentally pushing the wrong button on an intravenous pump. Lapse - memory lapse such as forgetting to administer medication.
2.1.2. A rule based mistake occur within healthcare when an indivdual is already aware of rules and procedure however applies the incorrect rule (Higham & Vincent, 2020). Knowledge-based mistakes occur when there is a gap in knowledge or skill/training of the clinician as well as a deep fixation on a hypothesis, resulting in the clinician being unable to think of alternate solutions (Bindra et al., 2021).
2.1.2.1. Examples include: Rule based mistake- Embarking on a treatment plan for influenza when the patient has meningococcal sepsis Knowledge based- Treating a patient with a rare condition in which you have no experience with treating.
2.2. Error wisdom and error reduction: 'Error wisdom' (Reason, 2004) is the ability to identify, respond to and recover from the initial indications that an adverse event or clinical incident is likely to occur.
2.2.1. Error wisdom is important for clinicians to adopt as it is essentially the ability to learn from mistakes/errors. The ability for a clinician to turn an adverse event into a 'close call' is crucial for providing safe and quality care to patients.
2.2.1.1. Error reduction requires clinicians to minimise risk through eating well, sleeping well, follwoing procedure as well as performing detailed risk assessments in which potential risks and hazards are identified and measures/protocols are put in place to reduce the chance for them to occur (Pascarella et al., 2021).
2.2.1.1.1. Examples of risks include ergonomic hazrads from lifting, any spill hazards, clinician fatigue, as well as work-related stress.
3. The 5 Models of Governance
3.1. International
3.1.1. The World Health Organisation (WHO) aims to promote health, provide education and to improve access to health care ervice across the globe (World Health Organization, 2024).
3.1.1.1. An example of WHO directly impacting nurses is their Global Strategic Directions for Nursing and Midwifery (2021–2025) which provides guidance for all registered nurses and midwives
3.2. State Organisations
3.2.1. Australian states and territories have their own agenices and organisations. For Victoria, the Department of Health provide evidence-based guidelines, provide health services to all individuals and work with communities to improve health outcomes within the state (Department of Health Victoria, 2023)
3.2.1.1. An example includes the 2024 legislative reform that allows midwives to prescribe and/or supply any Schedule 2,3,4 or 8 medicine, including those for medical abrotions (Victorian Government Gazette, 2024).
3.3. National Safety and Quality Health Service (NSQHS) Standards
3.3.1. There are 8 standards that are required to be upheld at all times, devloped by the commission, the Australian Government, states, private sector providers, clinicians and patients with the aim to prevent harm to the public and improve the quality of health care (Australian Commission on Safety and Quality in Health Care, 2021).
3.3.1.1. 1. Clinical Governance – Ensures a safety and quality framework within healthcare organizations. 2. Partnering with Consumers – Involves patients, families, and carers in care planning. 3. Preventing and Controlling Infections – Focuses on infection prevention and antimicrobial stewardship. 4. Medication Safety – Reduces medication errors and promotes safe medication use. 5. Comprehensive Care – Ensures coordinated, risk-based care tailored to patient needs. 6. Communicating for Safety – Improves communication to minimize errors and enhance patient safety. 7. Blood Management – Ensures safe and appropriate use of blood and blood products. 8. Recognizing and Responding to Acute Deterioration – Enhances timely response to critical patient conditions.
3.3.1.1.1. These set-out standards provide registered nurses and midwives with a clear expectation of their duty of care with regard to providing quality and safe care (Department of Health. Victoria, 2023)
3.4. Organisational Standards
3.4.1. With regard to the NSQHS stnadards, they are utilised by the Australian Council on Healthcare Standards (ACHS) to determine the quality, efficiency and effectiveness of the healthcare provider (ACHS, 2017).
3.4.1.1. Information with regard to the healthcare provider's accreditation is publicly available to consumers, and it allows healthcare providers access to feedback and areas of improvement, both helping to improve patient experiences and outcomes.
3.5. Registration and Practice Standards
3.5.1. The Australian Health Practitioner Regulation Agency (AHPRA)
3.5.1.1. AHPRA works alongside 15 National Boards to implement an accedridation scheme for healthcare proffessions, helping to set standards across the board and help protect the public (AHPRA, 2023).
3.5.1.1.1. AHPRA announced a streamlined pathway program to take effect in April 2025 for Internationally Registered Nurses to register in Australia, helping to boost the supply of experienced, safe and qualified nurses with different backgrounds in Australia (NMBA, 2024).
3.5.2. Nursing and Midwifery Board Australia (NMBA)
3.5.2.1. The NMBA (a subsection of AHPRA) works to guarantee that both enrolled and registered nurses in Australia are trained to a good standard, qualified and safe to practise (Nursing and Midwifery Board of Australia, 2023).
4. Risk Management
4.1. Clinical Risk is a term used to describe the level of risk to patient safety as well as the risk to the healthcare personnal, with regard to the current procedures, equipment and precautions in place if an adverse event were to occur
4.1.1. Clinical Risk management is vital to improve patient outcomes and preventing any circumstances that could expose any and all individuals within the clinical setting to adverse and unwanted events (La Russa & Ferracuti, 2022)
4.1.1.1. An adverse event includes a needle stick injury in which nurses are trained to handle needles within a safe manner to minimise these risks.
4.2. Safe Work Australia (2024) has identified four steps when dealing with risk: 1. Identify the risk – what could go, or has gone, wrong? 2. Assess the frequency and severity of the risk – what are the chances of the incident happening and what would be the impact if it did? 3. Reduce or eliminate the risk – what can we do about it? How can we minimise it? 4. Assess the costs saved by reducing the risk, or the costs of not managing the risk.
4.2.1. For example, within a clinical setting there is a risk of a nurse administering an incorrect medication to a patient which could result in fatal consequences.
4.2.1.1. As such, there are procedures involved that recognise this risk and attempt to minimise it such as the 8 rights of administration protocol, the three forms of identification protocol and needing a medication check from another nurse when administering certain medications (McGowan et al., 2023).
5. Incident Reporting
5.1. Acknowledging mistakes and learning from those mistakes is the essence incident reporting within the healthcare setting, helping to improve the quality of care and reduce risks within a clinical setting (Sergi & Davis, 2023).
5.2. To measure the severity of an incident, each incident is given a rating, called the incident severity rating (ISR). It is based on the actual and potential impact to those involved in the incident, and he actual and potential impact to the organisation.
5.2.1. ISR classification levels according to severity: • ISR 1 – severe/death • ISR 2 – moderate • ISR 3 – mild • ISR 4 – no harm/near miss. (Safer Care Victoria, 2023)
5.2.1.1. These classification levels help nurses reflect on pass incidents and errors, and prioritise what needs addressing.