Adverse Events in Healthcare Flashcards
Define “Adverse event”
An unintended event resulting from clinical care and causing patient harm
Define “Near miss”
A situation in which event or omissions, arising during clinical care fail to develop further, whether or not as the result of compensating action, thus preventing injury to a patient
What does NRLS stand for?
National Reporting and Learning System
What proportion of admissions result in some level of harm to a patient, causing an adverse event?
1 in 10
Give examples of adverse events occurring in hospital
Wrong site of surgery, medication errors, pressure ulcers, wrong diagnosis, failure to treat, patient falls, hospital acquired infection, medication adverse events
How many adverse events occur every year in the NHS? What is the cost?
850,000 per year, costing £3.4 bn in total
What 8 sources of information can outline whether a hospital is safe or not?
- Hospital mortality data
- Data on other measures of safety
- Reports of Never Events / Serious Incidents
- NHS safety thermometer
- Patient safety dashboards
- Monitoring / Inspections by regulators
- CQC
- NHS Improvement
What is an SMR?
Standardised Mortality Rate
What % of Hospital Deaths are Avoidable?
3.4%
Why are Hospital Standardised Mortality Rates not fit for purpose? 4 points
- Mistaken concept, it is common for people to die in hospital
- Non-hospital care in hospitals (Palliative care) - variation in communities
- Data vagaries
- Case-mix adjustment
What are the three types of errors which can occur in healthcare?
- Knowledge-based
- Rule-based
- Skills-based
What is a Violation? What are the four types
When professionals intentionally break the rules
- Routine violation
- Situational violation
- Reasoned violation
- Malicious violation
What is an Active Failure?
Unsafe acts committed by people in direct contact with a patient
When is a Latent Error?
Errors which develop over time, laying dormant until they combine with other factors / active failures to cause an adverse event
What is “Blame Culture”?
It reduces the focus on true causes of failure, and individuals cover up errors for fear of retribution
