1) Patient Safety and Quality in the NHS Flashcards
What is clinical governance?
A framework through which NHS organisations are accountable for continuously improving the quality and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.
How can human factors be eliminated to give a safer design?
- Avoid reliance on memory
- Make things visible
- Review and simplify processes
- Standardise common processes and procedures
- Routinely use checklists
- Decrease the reliance on vigilance
Describe the swiss cheese model of accident causation.
- There are successive layers of defences, barriers and safeguards (like cheese layers)
- Hazards are holes in the cheese - they can be active failures or latent failures (conditions)
- You don’t want holes in the same place in many layers of things can slip through.
What are the main components of a clinical audit? i.e. what have you got to do to perform one
- Choose topic:
1) Setting standards
2) Measuring current practice
3) Comparing results with standards (criteria)
4) Changing practice
5) Re-auditing to make sure that the practice has improved
What are three types of error that commonly occur?
- Slips/lapses (error of action)
- Mistake (error of knowledge/planning)
- Violation (intentional deviations from protocols, standards, safe operating procedures or other rules)
What are active failures with reference to the swiss cheese model of accident causation?
Happen at the sharp end of practice, closest to the patient - a direct failure. These are issues that can build up with other problems (holes) to generate a failure.
What are latent conditions (failures) with reference to the swiss cheese model of accident causation?
Predisposing conditions that make active failures more likely to occur - training, policy etc. These are issues that can build up with other problems (holes) to predispose to a failure.
What is a clinical audit?
A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against criteria and the implementation of change.
What are the implications clinical governance for the work of doctors?
- Accountability - corporate manslaughter, assessment and revalidation
- How systems are implemented
- Hierarchy use and abandonment (when it works and when it should be left i.e. Elaine Bromley)
What is an adverse event?
An injury caused by medical management (rather than the underlying disease) that prolongs hospitalisation, produces a disability, or both. However, it is important to note that an adverse event can be unavoidable e.g. prescription of a drug for the first time causes side effects.
What does the term equity mean?
Everyone with the same need gets the same care.
What does we mean when we use the term inequitable care in England?
Patients across England vary in the extent to which they receive high quality care and very in their access to care.
Suggest some types of PREVENTABLE adverse events.
- Surgical mistakes (foreign object left behind, wrong procedure, wrong site)
- Transfusion of blood of the wrong group
- Wrong dose/type of medication given
- Medication administered incorrectly (e.g. in Wayne Jowett chemo been given intrathecally instead of intravenously)
Why do medical errors happen?
- Everyone is fallible/makes mistakes
- Most medicine is complex and uncertain
- Most errors result from “the system” – e.g. inadequate training, long hours, ampoules that look the same, lack of checks etc.
- Personal effort is necessary but not sufficient to deliver safe care
What is the NHS outcomes framework?
Specific national outcome goals and indicators in 5 domains, linked to payments and financial incentives. It provides a national overview of how the NHS is performing, holds the Health Secretary and NHS CB accountable for public money and acts as a catalyst to change NHS culture and behaviour to drive up quality.
