Block 11 Flashcards
Define quality in terms of healthcare
the extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
Main functions of the clinical record
Support patient care
Improve future patient care
Social purposes at the request of patients
Medico-legal document
Medical functions of the clinical record
- Ensure clarity of diagnosis
- Record treatment plans
- Enable comprehensive monitoring
- Help maintain a consistent explanation for the patient
- Ensure continuity of care
How do clinical records assist in the clinical care of the practice population?
- assesses health needs of the population
- identifies target groups enabling call + recall programmes
- monitor progress of health promotion initiatives
- supports medical audit
- provide pts. w an opportunity to contribute to their record
List some non-clinical purposes of the clinical record
- used to support claims for benefits + other additional social support
- providing reports + info for 3rd parties
- providing legal evidence for a patient that makes a claim against a 3rd party
Advantages of handwritten notes for clinical record
- continuous - reads like a book
- writer identified
- usually written at time you see the pt → contemporaneous
Disadvantages of handwritten notes for clinical record
- structural problems - if page goes missing/falls out can mess up structure of all notes
- legibility issues
- functional problems with maintaining it
- must remember to date and sign it or it is not valid
Benefits of computerised clinical records
- problem orientated → driven by coding
- gives audit trail
- searchable
- helps w provision of disease registers as problems can be easily traced back to code
Disadvantages of computerised records
- dependent on doing correct coding → if incorrect can impact patient safety
- Wannacry - ransom attack, data breach
How might electronic recording impact communication skills
- patient may feel like you’re ignoring them
- can be distracting
Key differences between hospital and primary care clinical records
GP
- paper light
- increasingly computerised
- patient orientated
- correspondence rich - long entries
- multiple records for different professionals (due to referrals etc.)
Hospital
- largely paper-based
- disease orientated
- shared by all in hospital
- slow + poor quality computerisation
What should be included in the clinical record? (TIP: think of a typical consultation structure!)
- presenting symptoms + reasons for seeking healthcare
- relevant clinical findings
- diagnosis + important differentials
- options for care + treatment (safety netting - who pts. can contact etc.
- discussions about risks + benefits of care + treatment
- decisions abt care + treatment
- action taken + outcomes
Why type of clinical record do all patients in England have?
Summary Care Record
contains:
- Name, address, date of birth and NHS number
- Medication
- AllergiesDifferences between paper + electronic records
Paper - Continuous, portable, writer identified, legibility issues, must be dated and signed
Electronic - Problem orientated, searchable, structured, safer prescribing, clinical decision support software
What is the use of records in audit, research and management?
Support clinical audit
Facilitates clinical governance - audit trail, support seasonal initiatives e.g. flu vaccines
Facilitates risk management - prescription alerts, reminders
Support clinical research - identify pts. eligible for a study by searching the database
What is Clinical governance? (this is to help understand role of clinical records in management)
system through which NHS organisations are accountable for continuously improving the quality of their service
What is the purpose of antenatal screening tests?
to identify major abnormalities
Types of antenatal screening tests: (3main elements)
- Screen for infectious diseases:
Hep B
HIV
Syphillis
- Screen for Sickle cell and Thalassemia
- Screen for foetal anomalies (FASP)
- Down’s syndrome
- Edwards’ syndrome
- Patau’s syndrome
incl. 20wk scan for 11 physical conditions:- abdominal wall defects
- renal agenesis
- cleft lip
- congenital diaphragmatic hernia
- congenital heart disease
- triosmy 13
- triosmy 18
- NTDs
List the 11 physical conditions scanned for at the 20wk scan:
- abdominal wall defects
- renal agenesis
- cleft lip
- congenital diaphragmatic hernia
- congenital heart disease
- triosmy 13
- triosmy 18
- NTDs
What are the types of newborn screening? (3main elements)
- Physical examination => within 72hrs
- overall check of eyes, heart -> congenital defects, hips -> DDH + testicles(male) - Hearing -=> 4-5 wks ideally but up to 3months
- Blood spot => ~5days pld
- screen for 9 rare conditions:
SCD
CF
Congenital hypothyroidism
6 inherited metabolic diseases:- [phenylketonuria (PKU)]
- [medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
- [maple syrup urine disease (MSUD)
- [isovaleric acidaemia (IVA)
- [glutaric aciduria type 1 (GA1)
- [homocystinuria (pyridoxine unresponsive) (HCU)]
What was the main outcome of the Peel Committee Report (1970)?
Sufficient facilities should be made available for 100% of childbearing women to give birth in hospital
What is the medical model of birth?
- Birth seen as a dangerous journey
- only normal in retrospect, therefore assume the worst
- Low threshold for intervention (to fix defective bodies)
Why are childhood poisonings declining?
Due to more child resistant containers + safer medicines
How do most adolescents die?
> 50% due to RTCs - boys more likely to die than girls
Types of injuries in children
- Falls
- Head injuries
- Road traffic collisions
- Drowning
- Swallowed foreign body
3 most common types of cancer in children
- Leukaemias
- Brain + CNS tumours
- Lymphomas
collectively account for more than 2/3 of all cancers diagnosed in children aged btwn 0-14
Common causes of morbidity in children
- Trauma
- Malignancy
- Respiratory disorders
- Infections
- Neurological diseases
- Congenital abnormalities
Examples of CNS diseases in children
- Epilepsy
- Cerebral palsy
- Neurodevelopmental disorders
- Birth aspyhixa
- Hypoxic-ischaemic encephalopathy
6 common chronic illnesses in the UK in children
Cystic Fibrosis
Diabetes mellitus
Epilepsy
IBD
Neurodisability / CP
Psychiatric illness
Obesity
Asthma
Why are males more likely to die than females?
Higher suicide rates Violence related Road traffic accidents Behavioural differences between males and females - More likely to take part in 'risky' behaviour
Why does poverty increase your risk of poor health?
Poor nutrition
Overcrowding
Lack of clean water
Harsh realities that may make putting your health at risk the only way to survive orkeep your family safe
4 main types of neglect:
PHYSICAL
- not providing basic need: food, clothes, shelter
- failing to adequately supervise or provide safety
EMOTIONAL
- Failing to meet a child’s needs for nurture and stimulation,
- e.g. ignoring, humiliating or isolating
MEDICAL
- not providing appropriate health or dental care
- ignoring medical recommendations
- or refusal of care
EDUCATIONAL
- Failing to ensure a child receives an education.
Signs of neglect
Malnutrition, begging, stealing or hoarding food
Poor hygiene, matted hair, dirty skin, body odour
Unattended physical or medical problems
Comments from a child that no one is home to provide care
Being constantly tired
Frequent lateness or absence from school
Inappropriate clothing, especially inadequate clothing in winter
Frequent illness, infections or sores
Being left unsupervised for long periods
Signs of emotional abuse
Delayed or inappropriate emotional development
Loss of self-confidence or self-esteem
Social withdrawal or a loss of interest or enthusiasm
Depression
Headaches or stomach aches with no medical cause
Avoidance of certain situations, such as refusing to go to school or ride the bus
Desperately seeks affection
A decrease in school performance or loss of interest in school
Loss of previously acquired developmental skills
4 main types of abuse:
PHYSICAL ABUSE
Deliberate aggressive actions on the child that inflict pain
NEGLECT
- failing to provide for child’s needs
SEXUAL ABUSE
- inappropriate sexual touching or acts on child
PSYCHOLOGICAL ABUSE
- behaviours towards children that cause mental anguish or deficits
Who is responsible for shaping child policies + procedures in local areas?
Local authorities
Local Safeguarding Children’s Boards (LSBCs)
Patient safety
Coordinated efforts to prevent harm to patients caused by the process of health care itself
Adverse event
Unintended event resulting from clinical care and causing patient harm
Near miss
situation in which events or omissions, arise during clinical care fail to develop further,(whether or not as the result of compensating action), thus preventing injury to a patient
Swiss cheese model of accident causation
Although many layers of defence lie between hazards and accidents, there are flaws/weaknesses in each layer that, if aligned, can allow the accident to occur
Abortion Act 1990
Allow abortion if:
Pregnancy not past 24th week
Continuation would cause risk of injury to physical + mental health of mother (including risk of life)
Substantial risk child will suffer physical/mental abnormalities (to be seriously handicapped
Anti-abortion arguments:
Termination of life of a foetus
Human foetus has moral status of an innocent person
Impermissible to terminate life of an innocent person
Therefore abortion = impermissible
Social factors leading to teen pregnancy
Poverty In care Children of teen mums Low educational achievement Low expectations Mental health problems Crime
Children Act 1989 and 2004
All organisations working with a children have a duty in
helping safeguard + promote welfare of children
Techniques for talking with children
- try to maintain sense of humour
- eye contact
- turn talking to elicit information
Individual error
- Forgetfulness
- loss of concentration
- not paying attention,
- moral weakness
System lvl error
conditions under which an individual works:
- Inadequate education
- lack of resources
- poor quality equipment
- unsafe environment
Knowledge-based error
Forming wrong intentions/plans as a result of inadequate knowledge or experience
Serious adverse event
when result of this harm is:loss of life, threatened loss of life, major complications e.g. limb loss, organ failure, prolongation of hospitalisation
Serious incidents
Events where the potential for learning is so great, OR the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using resources to investigate and act
Never events
serious incidents that are entirely preventable because guidance/safety recommendations providing strong systemic protective barriers are available at a national lvl + shld have been implemented by all healthcare providers
14th leading cause of global disease burden
patient harm
Examples of adverse events
- Wrong site surgery
- Medication errors
- Pressure ulcers
- Wrong diagnosis
- Failure to treat
- Patient fall
- Hospital acquired infection
- Medicine adverse effects (side effects)
Healthcare quality should be:
Safe
- minimise risk + harm to patients
- avoid preventable injuries
Timely
- reduce waits + harmful delays
Effective
- based on scientific knowledge
Efficient
- avoid waste - value for money
Equitable
- fair + based on needs only
Patient centred
- respectful of + responsive to individual pts.
Limitations of hospital standardised mortality rates:
- dependent on hospital care - hospitals are only part of pt’s journey
- data vagaries - adjustment of risk is dependent on accurately coded data
- choice of case mix adjustment model
- only ~5% of hospital deaths are avoidable + no association w HSMR
What is an active failure?
Where an act can be directly linked to an event e.g. doctor prescribing high dose
An error is:
an error is made unintentionally, and it’s contributed to by a lack of knowledge, experience or skill
Rule-based error:
Applying the wrong rule at a familiar pattern
i.e Encounter relatively familiar problem but apply ‘wrong’ rule (i.e. missaplication of a good rule or application of a bad rule)
Skills based errors
Attention slips and memory lapses, due to interruptions
+ distractions
Violations
when an individual knows what they shld do but chooses to do something else; may have been done with the intention of increasing speed or efficiency that may result in potentially avoidable patient harm
What are the different types of violation?
ROUTINE
=> Regularly performed shortcut due to poor system design,
may be accepted over time
REASONED
=> Deliberate deviation from protocol thought to be in patient’s best interests at the time
MALICIOUS
=> Deliberate deviation from protocol with intention to cause harm
SITUATIONAL
=> Context-dependent deviation from protocol due to (e.g. time-pressure, lack of supervision, low staffing)
Latent failures
- longstanding issues usually unnoticed until harm is caused
- e.g. understaffing of pharmacists - not enough prescription checks
- develop over time + lay dormant until they combine w other factors or active failures to cause adverse event
What happens in Blame culture and what’s its effect?
- individuals cover up errors for fear of retribution
- reduces focus on true causes of failure
Normalisation of Deviance culture
failings happen because staff become blind to wht is going on around them assuming tht the practices being tolerated are normal §
Explain how understanding that human factors are a major contributor to adverse events can change awareness of patient harm?
Human factors acknowledges:
○ the universal nature of human fallibility
○ the inevitability of error
○ that error is not necessarily due to incompetence
How can we apply human factors thinking to the work environment?
- Avoid reliance on memory
- Make things visible
- Review and simplify processes
- Standardise common processes and procedures
- Routinely use checklists
- Decrease the reliance on vigilance
Situations associated w an increased risk of error
- Unfamiliarity with the task
- Inexperience
- Shortage of time
- Inadequate checking
- Poor procedures
- Poor human equipment interface
Ways to improve patient safety:
- increase nurse and Dr patient staffing ratios
- Create a patient safety culture
• Improve team work and communication
• Open reporting and learning from incidents
• Safety huddles
• Work with frontline teams, involving everyone from cleaners to
consultants - Electronic early recognition of deteriorating patient
- Standardise approaches to high risk patients
- Promote safer prescribing
- Promote hand hygiene
NHS systems in place to prevent errors:
NRLs - National reporting + learning system for:
- anonymous reporting, near misses and learning from
mistakes
MHRA - Medicine and healthcare-products regulation agency
- ensures medicines and equipments meet standards of safety, quality, performance and effectiveness
NPSA - National patient safety agency
- coordination of reporting and learning from mistakes that affect patient safety.
Measuring hospital safety
Hospital mortality data
Data on other measures of safety - Reports of never events and serious incidents,
NHS safety thermometer, patient safety dashboards
Monitoring and inspections by regulators - Care quality commission (CQC), NHS
Improvement
What shld we do when adverse events occur?
Report it - Incident reporting systems
Assess its seriousness
Analyse why it occurred - Root cause analysis
Be open and honest with the affected patient and apologise - Duty of Candour
Learn from the event and put in place actions to reduce risk of repeat
Most common form of child abuse
Neglect
Induction
any intervention that starts labour
Psychosocial model of labour
Birth is a landmark event in a woman’s life
When was the Midwives institute formed?
1881
What was the aim of 18th Century lying-in hospitals?
to help destitute, homeless or poor married women who were pregnant + who didn’t have access to physicians
Why did women cared for in institutions by midwives have a decreased risk of childbed fever (puerperal sepsis)?
because midwives instituted hand hygiene + prevention of cross contamination
Results of the O’Driscoll trial
- very high spontaneous delivery rates
- very low prolonged birth rates
**this trial highlighted it’s not the obstetric interventions but the caring interventions in terms of continuity of care
Medical model of birth
Birth seen as a dangerous journey, only normal in retrospect, therefore assume the worst
Social model of birth
Birth is seen as a normal physiological process, which women are uniquely designed to achieve
How can we naturally aid oxytocin lvls for labour?
- create calm + safe environment
- encourage vaginal fullness, pressure on cervix, pelvic floor pressure + crowning to trigger +ve feedback loop ⇒ Ferguson’s reflex
- more stretch → more oxytocin
- allow women to develop own endogenous opioids → Endorphins
Benefits of MDT working in terms of pregnancy
- better patient satisfaction
- more effective healthcare delivery
- higher lvls of innovation in ways of caring for pts.
- lower lvls of stress
- more consistent communication w peers
What problems may occur with breastfeeding?
Nipple pain
Engorgement
Mastitis
Inverted nipple
Ankylossia (tongue ties)
Sleepy baby
Indicators of a successful breastfeed:
Baby - Audible and visible swallowing, sustained rhythmic suck, relaxed arms and head, moist mouth, regular soaked nappies
Women - Breast softening, no compression of nipples at end of feed, relaxed
Main aims of antenatal care:
Monitor progress of pregnancy to optimise maternal and foetal health
Develop a partnership between woman and health professional
Exchange information that promotes choice - About lifestyle, location of birth, etc
Recognise deviations from the norm and refer appropriately
Increase understanding of public health issues
Provide opportunities to prepare for birth and parenthood
Factors that can hinder effective MDT working:
Separate documentation
◦ Poor working relationship ◦ Lack of awareness and appreciation of the roles and responsibilities of others ◦ Limited time and resources ◦ Overlapping of roles and duplication of services ◦ Poor communication ◦ Lack of information sharing ◦ Lack of collaboration ◦ Lack of trust and confidence in the abilities of other agencies ◦ Increased workload ◦ Lack of appropriately trained staff ◦ Constant re-organisation
Fraser guidelines applies specifically to
advice and treatment about contraception and sexual health
What does NICE do?
sets standards for treatment
Who enforces the NICE guidelines?
Royal Colleges
GMC
Professional audit
How can consumer protection be improved?
- revalidation by the GMC
- appraisal by peers
- transparency + accountability
- increasing transparency in comparative performance
What are the 4 RIGHTS OF CONSUMERS?
- The right to safety - non-maleficence
- The right to be informed - informed consent
- The right to choose - appropriate choices relevant to
- The right to be heard - Patient voice and legal framework
What are the 4 rights of consumers?
- The right to satisfaction of basic needs - access to healthcare
- The right to redress - Patient voice and legal framework
- The right to consumer education - relevant information provided to make a decision
- The right to a healthy environment - provide reassurance and monitor quality
NHS was created on basis of 3 core principles:
- That it meet the needs of everyone
- That it be free at the point of delivery
- That it be based on clinical need, not ability to pay
NHS was created on basis of 3 core principles:
- That it meet the needs of everyone
- That it be free at the point of delivery
- That it be based on clinical need, not ability to pay
Causes of preventable patient deaths
- poor clinical monitoring
- diagnostic errors
- inadequate drug and fluid management in near equal parts
When is a patient’s death judged as avoidable?
When there was a problem in care that contributed to the patient’s death
problems in care defined as:
- acts of omission (e.g. failure to treat according to best evidence)
- acts of commission (e.g. incorrect treatment or management)
- unintended harm due to complications of care
Main causes of hospital deaths are related to:
- thoracic + respiratory problems - 31%
- abdominal - 12%
- intracranial - 10%
Gives examples of types of medical errors
Medication - wrong dose or wrong drug
Surgery - wrong procedure,
poor infection control
How is patient safety trying to be improved
- targeted efforts to control/reduce MRSA + C.difficile infection rates using reporting + fines
- introduction of never events
- reporting systems but some medical staff may be too busy + not have time use these systems
PROMs
Patient reported outcome measures => measure a patient’s health status or health-related quality of life at a single point in time, and are collected through short, self-completed questionnaire
- allow patients to self-report and uses their views to assess their health status + well-being
DUTY OF CANDOUR
a statutory (legal) duty to be open and honest with patients (or ‘service users’), or their families, when something goes wrong that appears to have caused or could lead to significant harm in the future.
Who does the “duty of candour” legal framework apply to?
All health and social care services registered w CQC
Give 3 examples of consumer protection agencies
- NICE
- NHS improvement formerly ‘monitor’
- CQC - care quality commission
What does “NHS improvement” do?
now merged with NHS England ensures financial obligations are met in terms of balancing income + expenditure
The SHMI covers:
the number of patients in England who died in hospital or within 30days of being discharged
Role of Health Protection Agency
role is to protect the health + well-being of the population by e.g. monitoring infection rates
Human Fertilisation and Embryology Act (1990):
A woman shall not be provided with [fertility] treatment services unless account has been taken of the welfare of any child who may be born as a result of the treatment (including the need of that child for a father
How many IVF cycles can women get on the NHS according to NICE guidance?
for women btwn. 23 -39 up to 3 cycles should be offered
Cost effectiveness of IVF depends on
- treatment success rates
- multiple pregnancies
- cost of treatment
Which organisation decides who can have NHS funding for IVF treatment?
Local CCGs - clinical commissioning groups
What should you do before conducting an intimate examination?
Explain to the patient why an examination is necessary and give the patient an opportunity to ask questions
Explain what the examination will involve
Get consent and record that the patient has given it
Offer a chaperone
Give the patient privacy to undress
