1.1 Patient Safety and Quality in the NHS

Question 1

Why is it important that the NHS is safe?

Answer 1

To reduce patient deaths

Question 2

Why is it important that the NHS is effective?

Answer 2

So nobody suffers unnecessarily

Question 3

Why is it important that the NHS is patient-centred?

Answer 3

To focus on the patient’s needs and priorities

Question 4

Why is it important that the NHS is equitable?

Answer 4

No group of people is left out

Question 5

What does variation in the NHS suggest?

Answer 5

Not everyone is getting the best care
There may be waste of services
There may be inequity

Question 6

What is equity?

Answer 6

Everyone with the same need gets the same care

Question 7

What is an adverse event?

Answer 7

An injury caused to a patient by medical management which results in a prolonged hospitalisation or a disability

Question 8

What is preventable harm?

Answer 8

An adverse event that could have been stopped from happening

Question 9

What is unavoidable harm?

Answer 9

An adverse event happening that could not have been prevented eg. drug reactions

Question 10

Give an example of a preventable adverse event?

Answer 10

Retained objects after surgery
Surgery on wrong body area
Wrong dose of medication

Question 11

What is a never event?

Answer 11

An event which should NEVER happen. It only happens due to a failure in communication or caution.

Question 12

Give 2 reasons why mistakes in healthcare can happen

Answer 12

Poorly designed healthcare systems

Culture and behaviour

Question 13

Why is it important to not rely solely on individuals?

Answer 13

Human error
Medicine is very complex
May have inadequate training
People make mistakes

Question 14

What is a ‘human factor’?

Answer 14

A psychological response to a situation which is highly predictable but often poorly anticipated.
Eg. using the wrong medicine if it is in the similar packaging to the right medicine

Question 15

When can diagnosing become unsafe?

Answer 15

Wrong equipment available

System unreliable

Question 16

What happens if a system is not made safe in the long-run?

Answer 16

Short term fixes
Mistakes are tolerated
Degrading of safety
HCP rush procedures

Question 17

Define an active factor in the ‘Framework of Error’

Answer 17

An act that leads to patient harm

Question 18

Define a latent condition in the ‘Framework of Error’

Answer 18

Predisposing factors which make active factors more likely to occur

Question 19

Describe the Swiss Cheese Model

Answer 19

Latent factors line up to produce an action which causes harm to the patient. Successive layers of defences, barriers and safeguards need to be passed.

Question 20

How can the risk of human factors be decreased?

Answer 20

Avoid relying on memory
Make important things more visible
Simplify processes
Standardise process
Use checklists

Question 21

What is a ‘loss of situational awareness’?

Answer 21

Common response in a high-pressure situation where the sense of time passing is lost. The same thing for a patient is done repeatably even when it is not working.

Question 22

What is clinical governance?

Answer 22

Delivering on the duties of the NHS to put in place monitoring systems and to ensure a good quality of care

Question 23

What was brought in by the Health and Social Care Act 2012?

Answer 23

The NHS must secure continuous improvement by following the standards made by NICE

Question 24

What is a NICE quality standard?

Answer 24

Markers of high-quality, clinical and cost-effective patient care based off the best available evidence.

Question 25

What is a QOF?

Answer 25

Quality and Outcome Framework

Sets the national quality standard. Payments to a GP trust are calculated based on how well the QOFs are followed.

Question 26

What is a HRG?

Answer 26

A unit of currency which determine an equitable reimbursement for care services delivered by providers.

Question 27

What is the national tariff?

Answer 27

The national cost of a given procedure is set at a given rate. A trust is given x amount of money for y amount of procedures. An efficient trust will spend less on the procedure and make money but an inefficient trust will lose money.

Question 28

What is the CQC?

Answer 28

Care Quality Commission
Organisation which inspect the quality of procedures. They can make unannounced visits, issue warnings, fines, prosecutions and restrict activities/closure

Question 29

What is a clinical audit?

Answer 29

An investigation which looks at an area which is not performing well to see how it can be improved

Question 30

Describe the audit cycle

Answer 30

Choose topic –> Look at the criteria and standards by looking at the research evidence –> First evaluation –> Implement change –> Second evaluation –> Look at the criteria and standards again to see if there has been a positive change. Re-audit if necessary

Question 31

What is quality improvement?

Answer 31

Systematic efforts to make changes that will lead to better patient experiences and professional development.