1.1 Patient Safety and Quality in the NHS Flashcards
Why is it important that the NHS is safe?
To reduce patient deaths
Why is it important that the NHS is effective?
So nobody suffers unnecessarily
Why is it important that the NHS is patient-centred?
To focus on the patient’s needs and priorities
Why is it important that the NHS is equitable?
No group of people is left out
What does variation in the NHS suggest?
Not everyone is getting the best care
There may be waste of services
There may be inequity
What is equity?
Everyone with the same need gets the same care
What is an adverse event?
An injury caused to a patient by medical management which results in a prolonged hospitalisation or a disability
What is preventable harm?
An adverse event that could have been stopped from happening
What is unavoidable harm?
An adverse event happening that could not have been prevented eg. drug reactions
Give an example of a preventable adverse event?
Retained objects after surgery
Surgery on wrong body area
Wrong dose of medication
What is a never event?
An event which should NEVER happen. It only happens due to a failure in communication or caution.
Give 2 reasons why mistakes in healthcare can happen
Poorly designed healthcare systems
Culture and behaviour
Why is it important to not rely solely on individuals?
Human error
Medicine is very complex
May have inadequate training
People make mistakes
What is a ‘human factor’?
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
When can diagnosing become unsafe?
Wrong equipment available
System unreliable
What happens if a system is not made safe in the long-run?
Short term fixes
Mistakes are tolerated
Degrading of safety
HCP rush procedures
Define an active factor in the ‘Framework of Error’
An act that leads to patient harm
Define a latent condition in the ‘Framework of Error’
Predisposing factors which make active factors more likely to occur
Describe the Swiss Cheese Model
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.
How can the risk of human factors be decreased?
Avoid relying on memory Make important things more visible Simplify processes Standardise process Use checklists
What is a ‘loss of situational awareness’?
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.
What is clinical governance?
Delivering on the duties of the NHS to put in place monitoring systems and to ensure a good quality of care
What was brought in by the Health and Social Care Act 2012?
The NHS must secure continuous improvement by following the standards made by NICE
What is a NICE quality standard?
Markers of high-quality, clinical and cost-effective patient care based off the best available evidence.
What is a QOF?
Quality and Outcome Framework
Sets the national quality standard. Payments to a GP trust are calculated based on how well the QOFs are followed.
What is a HRG?
A unit of currency which determine an equitable reimbursement for care services delivered by providers.
What is the national tariff?
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.
What is the CQC?
Care Quality Commission
Organisation which inspect the quality of procedures. They can make unannounced visits, issue warnings, fines, prosecutions and restrict activities/closure
What is a clinical audit?
An investigation which looks at an area which is not performing well to see how it can be improved
Describe the audit cycle
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
What is quality improvement?
Systematic efforts to make changes that will lead to better patient experiences and professional development.
