4 Improving the Quality of Care Flashcards
What did the Harvard medical practice study 1991 reveal?
almost 4% of patients experience preventable harm
What did An Organisation with a Memory 2000 show?
1 / 10 hospital experiences experience a safety incident
What happened in the British Royal Infirmary in the 80s and 90s?
29 babies died during cardiac procedures
What problems were there with the British Royal Infirmary?
old boy’s network
culture of secrecy
lack of external monitoring
lack of transparency with families
What key recommendations can out of the British Royal Infirmary scandal?
patients should be more involved in decisions
more systematic and external forms of appraisal
more explicit concern with patient safety
What did Harold Shipman do?
killed 200 patients over 20 years
What did the 5th report on Harold Shipman show?
GMC prioritised profession over patients
need for culture change
more robust forms of regulation required
sharing of information between agencies required
What happened in the Mid-Staffordshire scandal?
substandard performance and unsafe care in A and E 2005-8
What were the key findings of the Mid-Staffordshire report?
27-45% higher mortality rates
patients neglected
overstretched staffing and poorly trained
prioritised targets over patient safety
What were the 6 themes for Francis’ reccomendations?
common values fundamental standards openness and candour compassionate, caring, and comitted nursing patient centred leadrership acurrate and useful information
How can latent errors lead to active errors?
enable, exacerbate, and condition active errors
Which framework is used to identify ‘root causes’ in healthcare?
Vincent’s framework
Name 2 key approaches for thinking about quality and safety
reporting and learning
culture and culture change
What is the aim of reporting and learning?
understand the who, what, where, when, and why
How did Weick and Sutcliffe 2003 define safety culture?
A set of assumptions and practices necessary for health care organisations to provide optimum care
