Block 32 Flashcards
What did the EUROCARE report compare?
Compared 5 year survival in patients across Europe.
What did the EUROCARE report show?
That the UK was performing less well than other European countries.
The UK had a lower average than Europe for colorectal cancer mortality.
Give 4 potential causes of the UKs poor performance in the EUROCARE report.
1) Differences in data collection.
2) Age differences.
3) Differences in pt. stage at presentation, social class and access to treatment.
4) Greater delays in pathways to diagnosis.
What happened as a result of the EUROCARE-II report?
The expert advisory group to the CMO generated the ‘Calman-Hine’ report.
Give 4 recommendations of the Calman-Hine report.
1) All patients should have access to a uniformly high quality of care.
2) Give public and professional education to allow recognition of early symptoms.
3) Give clear information to patients, carers and families about treatment options and outcomes.
4) Cancer services should be patient centred.
5) Primary care should be central to cancer care.
6) Recognise the psychosocial needs of patients and carers.
7) It is essential to register and monitor outcomes.
What were the 3 levels of care suggested to be a solution to inequalities in cancer care in the Calman-Hine report?
1) Primary care.
2) Cancer units serving DGHs.
3) Specialist cancer centres serving populations >1 million.
**The Calman-Hine report also recognised the ongoing importance of palliative care.
1) Describe the roles of cancer units which serve district general hospitals.
2) Describe the roles of specialist cancer centres.
1) Treat common cancers, perform diagnostic procedures, perform common surgeries, give non-complex chemotherapy treatment.
2) Diagnose and treat rare cancers, give complex chemotherapy, perform complex surgeries, give deep X-ray therapy.
Why was the Calman-Hine solution of creating 3 levels of care organised in such a way?
1) Unite commissioners, providers, local authorities and the voluntary sector.
2) Integrate care and deliver holistic care.
3) Target resources to where they are most needed.
4) To promote alliance between providers.
Why is there an emphasis on use of MDTs in cancer treatment?
Modern management involves many disciplines and the skills of different HCPs.
MDTs streamline and coordinate care so that it is not fragmented across different sites.
MDTs provide better outcomes.
1) Which HCPs are involved in the core MDT in cancer care?
2) Which HCPs are involved in the extended MDT in cancer care?
1) Physicians, oncologists, radiologists, histologists, specialist nurses and an MDT coordinator.
2) Physiotherapists, dieticians, palliative care teams and chaplains.
Give 3 roles of MDTS within cancer care.
1) Discuss all new diagnoses within the centre.
2) Decide on case management and inform primary care of updates.
3) Designate a specialist nurse to patients.
4) Audit cancer care processes.
5) Develop guidelines for the management of cancer care.
Give 2 benefits of concentrating specialist cancer care into cancer centres.
1) Better case management of lesser seen cancers due to high quality of expertise.
2) Services often only needed in complex cases, so more efficient than having these resources in all tertiary centres.
Give 2 disadvantages to concentrating specialist cancer care into cancer centres.
1) May mean that fewer services are available in smaller, local hospitals.
2) Geographical inequalities in services provided as it would be challenging to provide easily accessible services to more geographically isolated areas.
Describe the structure and role of cancer networks in the UK.
34 cancer networks and 12 strategic clinical networks in the UK.
Cancer networks produce local treatment guidelines.
Strategic clinical networks deal with cancer, CVD and dementia.
What is the aim of cancer networks?
To decrease inequalities in the care received by patients with cancer.
** Networks ensure that commissioners, provider, local authorities and the voluntary sector work together to deliver high quality care.
What are cancer registries?
A service responsible for registering all cancers that occur within their geographical area. There are 4 in the UK.
Describe 4 roles of the UK cancer registries.
1) Establish incidence and survival between different demographic and social groups.
2) Track efficacy of screening and primary prevention programmes.
3) Compare and evaluate quality of care between regions.
4) Evaluate the impact of social and environmental factors between areas.
What is meant by the term ‘cancer survival’?
The % of the study population who are alive for a given period of time following diagnosis (usually 5 years).
1) What is relative survival?
2) What is observed survival?
1) An estimate of the number of patients expected to survive compared with national mortality date.
2) Actual number of patients still alive after a specified length of time post-diagnosis.
1) What is net cancer specific survival?
2) What is crude probability of death?
1) The probability of surviving cancer in the absence of an other illness.
2) The probability of death from cancer in the presence of other causes of death.
**CPOD: determined by using LE tables and COD information.
What is meant by the following with regards to cancer care:
1) Structure
2) Process
3) Outcome
1) Facilities, resources and organisation of resources (clinics, consultants, nurses, mammogram scanners, GPs).
2) How the system works and how healthcare is provided (the % patients diagnosed at an early stage).
3) Results, changes in health status and PROMS (mortality rate and patient satisfaction).
1) What is the national cancer research network?
2) What does the national cancer research network do?
3) What is the national cancer research institute?
1) An institute established by the DoH in 2001 due to a need for the integration of research and cancer care.
2) It supports prospective cancer trials and trials performed by charity.
3) An institution developed in 2001 to develop common plans for cancer research and to avoid unnecessary duplication or studies/ effort.
State 3 roles of the national cancer research institute.
1) Invest in facilities and resources for research.
2) Maintain a cancer research database and analyse new research.
3) Develop research initiatives.
4) Coordinate clinical trials for new drugs.
Describe the aims of the national cancer research network.
To increase speed quality and integration of research to improve patient care.
Give 3 examples of psychological consequences of cancer treatment.
1) Psychologically demanding (it is supposed to help/ cure but in the short term makes patients feel worse).
2) Causes changes in appearance (loss or weight and hair). The change in body image can cause a loss of self-identification and loss of confidence.
3) Treatment is intense, so leaves little time for socialising and can cause patients to feel isolated which may cause depression.
4) Anxiety about potential side effects of treatment.
What is an adverse event?
An unintended event resulting from clinical care and causing patient harm whether physical or psychological.
What is a near miss?
A situation in which events 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 is a serious incident?
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.
What is a never event?
Never Events are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers.
Give 3 examples which can be classified as never events.
1) Wrong surgical site.
2) Retained instruments post surgery.
3) Wrong administration route for chemotherapy.
4) Inpatient suicide using collapsable rails.
5) Maternal death from postpartum haemorrhage after elective caesarean.
6) IV administration of concentrated KCl.
What is a standardised mortality ratio (SMR)?
A way of calculating and comparing death rates across different communities, where data is standardised for age and sex in order to allow you to compare like with like data.
What have hospital standardised mortality ratios been used for?
To identify hospitals as poor performing, and then some of the poorest performing hospitals are inspected and put into special measures in order to improve their outcomes.
Give 3 reasons as to why the validity of HSMRs has been disputed.
1) Mistaken concept - not unusual for people to die in hospital.
2) Dependent on non-hospital care - variations in planned places of death, completion of ALDs and available local services.
3) Discrepancies in data vagaries (coding and definitions) - makes it difficult to accurately compare.
4) The relationships between HSMRs and quality of care received has not been demonstrated - there is no real association between high SMRs and high avoidable deaths.
1) What are the most frequently reported adverse events in primary care?
2) What are the most frequently reported adverse events in secondary care?
1) Failure in diagnosis and delay in diagnosis.
2) Negligence (highest in obstetrics), error in medication dosing and error in medication delivery.
In order for a negative outcome to occur, what needs to happen?
A wide range of latent failures and active failures need to align (Swiss cheese model).
What are active failures?
Errors and violations having immediate negative results and are usually caused by an individual.
They are unsafe acts committed by people in direct contact with the patient.
What are latent failures?
Latent failures are caused by circumstances such as scheduling problems, inadequate training, or lack of resources which can result in an active failure.
Give 3 examples of active failures.
1) Omissions
2) Action slips/ failures
3) Cognitive failures (memory lapses or mistakes)
4) Violations
Give 2 examples of latent failures.
1) Management decisions
2) Organisational processes.
3) Poor working environmental conditions.
What are contributory factors?
These are factors that either influenced or caused a single event or chain of events that contributed to the incident. They can be positive or negative.
What is a root cause analysis?
A method of problem solving with a specific framework used for finding the root cause or fault of an incident.
What are the 2 categories of active failures?
Error based and violations.
1) What are the 3 types of error based active failures?
2) What are the 4 types of violations?
1) Knowledge based, rule based and skill based.
2) Routine, situational, reasoned and malicious.
Describe what is meant by the following types of error:
1) Knowledge based
2) Rule based
3) Skills based
1) Forming wrong plans as the result of inadequate knowledge or experience (e.g. Junior doctor misdiagnosis).
2) Misapplication of a rule or guideline to a relatively familiar situation (e.g. using an adult dosage on a child).
3) Unintended deviation of action from a plan or lack of ability to perform a task (e.g. attention slips and memory lapses).
Describe what is meant by the following types of violation:
1) Routine
2) Situational
3) Reasoned
4) Malicious
1) Normalisation of bad practice.
2) Context -dependent (time pressures, low staffing, lack of supervision).
3) Deliberate deviation from protocol thought to be in the patient’s best interests at the time.
4) A deliberate act intended to cause harm.
What is normalisation of deviance?
Where doing something improperly or wrong becomes the norm and therefore becomes the known way of doing something.
What 3 factors does a human factors approach to error acknowledge?
1) the universal nature of human fallibility
2) the inevitability of error
3) that error is not necessarily due to incompetence
What is done to try and minimise error cause by human factors?
Design aids in the workplace to try and minimise the likelihood of error and/or its consequences.
State 3 changes which have been applied to try and reduce errors caused by human factors.
1) Avoid reliance on memory.
2) Make things visible
3) Review and simplify processes
4) Standardise common processes and procedures
5) Routinely use checklists
6) Decrease reliance on vigilance.
**Basically the idea is to ‘design out error’.
What is the role of monitoring adverse events in relation to quality control? Name 3.
1) Track errors and gather data on the most common errors.
2) Target studies as to why an event has occurred and create interventions to prevent future occurrences.
3) Record near misses so the system can change before an adverse event happens.
4) Re-audit after an intervention to analyse efficacy.
5) Perform root cause analysis to identify actions necessary to eliminate risk of future event.
Name 3 systems which are in place to monitor adverse events and state what they do.
1) National patient safety agency (NPSA): Collect and analyse data about adverse event PLUS learn lessons and feedback to healthcare organisations.
2) National reporting and learning system (NRLS): Allows for anonymous reporting of incidents and is run by the NPSA.
3) Yellow card system: A reporting system for adverse drug reactions and adverse events associated with blood products. Run by the medicines and healthcare products agency (MHRA).
What are the 7 steps to patient safety?
1) Build a safety culture.
2) Lead and support staff.
3) Integrate risk management.
4) Promote reporting of adverse events.
5) Involve and communicate with patients and the public.
6) Implement solutions to prevent patient harm.
7) Learn and share safety systems.
Name 3 ways that patient safety could be improved.
1) Increase nurse and doctor patient ratios.
2) Create a patient safety culture.
3) Electronic early recognition of deteriorating patients.
4) Standardised approaches to high risk patients.
5) Promote safer prescribing.
6) Promote hand hygiene.
Name 5 steps that should be taken when involved (directly or indirectly) when an adverse event occurs.
1) Report it.
2) Assess the seriousness.
3) Analyse why it happened (RCA).
4) Be open and honest with the affected patient (duty of candour).
5) Learn from the event and put in place actions to reduce the risk of a repeat.
What is meant by ‘duty of candour’?
A legal obligation placed upon healthcare professionals to communicate to a patient if something has gone wrong or some harm has been caused.
**You are less likely to get sued if you communicate effectively and apologise then if you try to cover something up.
What is the NHS blood transfusion service?
Part of NHS blood and transplant; a special health authority who are accountable to the DoH.
Name 3 things that the NHS blood transfusion service does.
1) Test, process and store all blood received.
2) Promote donors to donate every 3-4 months.
3) Recruit new donors.
4) Invest in R&D
5) Provide 50% UK stem cell transplants.
What is the purpose of the blood safety and quality regulations of 2005?
They regulate how blood is stored and transported.
State 3 of the blood safety and quality regulations.
1) Blood is only transferred in an appropriate clinical scenario.
2) Blood is transported and packaged in accordance with validated procedures.
3) Vein traceability must be maintained (document donation, screening, storage, transfer and transfusion).
4) Wastage must be minimised.
What is screening?
Systematic application of a test to identify individuals at risk of a particular disease who warrant further investigation amongst persons who have not sought medical attention in order to decrease the risk of that disease or its complications.
Why is screening required?
1) There are limited options for primary prevention and treatment opportunities.
2) Allows the potential for early diagnosis.
3) Allows for earlier treatment and so increases the rate of effective treatment.
What is length bias?
An overestimation of survival duration due to the relative excess of cases detected that are asymptomatically slowly progressing,
What is Sojourn time?
The time between biological manifestation and clinical manifestation of a disease.
What does Sojourn time vary with?
The natural history of diseases.
Some diseases have a long Sojourn time which will give a better prognosis and more opportunities for screening, where as diseases with a short Sojourn time are more rapidly progressing and often have worse prognoses.
What is selection bias?
Selection bias is the bias introduced by the selection of individuals, groups or data for analysis in such a way that proper randomization is not achieved, thereby ensuring that the sample obtained is not representative of the population intended to be analyzed.
**In screening, there is the concept of ‘healthy screens’ meaning that the sort of person to ‘opt in’ to screening is generally more health aware. This can exaggerate any beneficial effects of a screening programme.
What is lead time bias?
Lead time bias refers to the phenomenon where early diagnosis of a disease falsely makes it look like people are surviving longer.
**Lead time is the extra time that the disease survives depending on how much earlier it was detected. It is inherent bias in screening as ‘disease survival’ is measured from the point of detection.
What is a consequence of lead time bias?
Survival is inevitably longer following diagnosis through screening because of the ‘extra’ Lead Time.
Because of this the appropriate measure of effectiveness is deaths prevented, not survival.
What are the consequences of length bias?
Diseases with a longer sojourn time are ‘easier to catch’ in the screening net.
Individuals with disease detected through screening tend to have a better prognosis than people who present with signs or symptoms.
By comparing prognosis for those screened against those not screened, there will be a distorted picture.
Give 5 examples of NHS screening programmes.
- NHS abdominal aortic aneurysm (AAA) programme
- NHS bowel cancer screening (BCSP) programme
- NHS breast screening (BSP) programme
- NHS cervical screening (CSP) programme
- NHS diabetic eye screening (DES) programme
- NHS fetal anomaly screening programme (FASP)
- NHS infectious diseases in pregnancy screening (IDPS) programme
- NHS newborn and infant physical examination (NIPE) screening programme
- NHS newborn blood spot (NBS) screening programme
- NHS newborn hearing screening programme (NHSP)
- NHS sickle cell and thalassaemia (SCT) screening programme
Why is the test used to screen for colorectal cancer a ‘good’ test?
High sensitivity and specificity (80-90% and 80-98%).
PPV of 2-5%.
