19.07.06 Clinical governance and risk managment

Question 1

What is clinical governance

Answer 1

A framework to ensure continuous quality improvement in health care. A quality assurance process, designed to ensure that standards of care are maintained and improved and that the NHS is accountable to the public.

Question 2

7 points of clinical governance

Answer 2

• Patient/user experience and involvement
• Clinical risk management. Adverse events, complaints.
• Research and effectiveness. Evidence-based practice
• Information management. Patient data- accurate, up to date, confidential, secure.
• Education, training, CPD
• Clinical audit= review of clinical performance. EQAs. Performance vs agreed standards.
• Review of current practices against agreed standards (ensures best care is given to patients)
• Staff, staff management.

Question 3

What is risk management

Answer 3

Systems in place to understand, monitor, minimise risks to patients and staff. To learn from mistakes and near misses.

Question 4

How does risk management minimise risks to patients

Answer 4

• Identifies what has gone wrong
• Understand the factors that influence this
• Learning lessons from any adverse events
• Ensuring actions are implemented to prevent recurrence.
• Putting systems in place to reduce risks

Question 5

What is a clinical incident

Answer 5

Any event which has (directly or indirectly) caused an adverse incident, error or user complaint or which may have a negative impact on patient care.

Question 6

Steps after a clinical incident is identified

Answer 6

• Report event through adverse incident reporting systems.
• Immediate remedial actions defined and implemented.
• Investigation: likelihood of recurrence and severity of impact if an incident did occur
• Root cause analysis: systematic review of an incident identifying immediate (root causes) and underlying (contributing) factors associated when an incident occurs.
• Implement process designed to reduce risk and impact.
• Monitor and review.
• Promote blame-free culture. Will encourage everyone to report problems and mistakes.

Question 7

What is a corrective action

Answer 7

Appropriate action taken to eliminate the root cause of a detected non-conformity or other undesirable situation and prevent reoccurrence.

Question 8

What is a preventive action

Answer 8

Action take to eliminate the cause of a potential non conformity or other undesirable situation.

Question 9

What is root cause analysis (RCA)

Answer 9

A systematic review of an incident identifying immediate (root causes) and underlying (contributing) factors associated when an incident occurs.

Question 10

Three key attributes of clinical governance

Answer 10

• High standard of care
• Transparent responsibility and accountability for those standards
• Constant dynamic of improvement.

Question 11

Who assumes legal responsibility for quality of care

Answer 11

• Trust boards (since 1999).

- Clinical governance is the mechanism by which that responsibility is discharged.

Question 12

What is risk

Answer 12

The potential that a chosen action, inaction or activity will lead to an undesirable outcome.

Question 13

List examples of risk management

Answer 13

Manual handling, COSHH assessments, prevention of infection, clinical risks

Question 14

What is manual handling

Answer 14

Risk assessment of all procedures with potential manual handling. Done to protect staff and samples.

Question 15

What is COSHH

Answer 15

Control of substances hazardous to health

Question 16

What does COSHH assess

Answer 16

Risk of substances and procedures. Should be done prior to undertaking a procedure.

Question 17

What percentage of patient contacts result in harm to patients or staff

Answer 17

10%. DoH 2000

-Half of these are preventable

Question 18

Categories of adverse incident

Answer 18

• Adverse incident
• Patient safety incident
• ‘No Harm’ incident
• ‘Prevented’ incident

Question 19

What is an adverse incident

Answer 19

-when an event occurs that causes harm to any person or damage/loss of property (Trust or individual). Includes near misses

Question 20

Patient safety incident

Answer 20

Any unintended or unexpected incident that could have or did lead to harm for one or more persons receiving NHS funded healthcare.

Question 21

‘No Harm’ incident

Answer 21

an unexpected or unintended incident which ran to completion but no harm, damage or loss occurred.

Question 22

‘Prevented’ incident

Answer 22

any incident that had the potential to cause harm but was prevented from occurring, resulting in no harm, damage or loss.

Question 23

What is the most common contributing factor to adverse incidents

Answer 23

Poor communication

Question 24

What is RIDDOR

Answer 24

Reporting of injuries, diseases and dangerous occurrences regulations

Question 25

Legal requirement within RIDDOR to report some incidences to Health and Safety executive, when

Answer 25

An incident or work related ill health that led to a member of staff being seriously injuring or off work for more than three days.

Question 26

When do you report to Medicines and Healthcare products Regulatory Agency (MHRA)

Answer 26

Any incident involving a medical device, even if caused by user error.

Question 27

When do you report to NHS litigation authority (NHSLA)

Answer 27

Any incident that will likely result in litigation.

Question 28

What do you report to National Patient Safety Agency (NPSA)

Answer 28

Patient safety incidents.