Clinical Governance Flashcards
What are the 4 pillars of clinical governance?
Responsibility and accountability.
Quality improvement programme.
Risk management Policies - SOPs, audits, and suitability assessments.
Identify and remedy performance issues - knowledge assessment, employee appraisals, training and development programme, CPDs.
Why is clinical governance important?
One of the essential NHS services.
Underpins excellence for all practitioners.
Key to patient safety and care.
Core of everything a pharmacist does.
What is a near miss?
A dispensing error that is detected before the patient or patient’s representative is handed the dispensed prescription.
What is a dispensing error?
A mistake which is detected after the medication has been given to the patient.
What are the different types of active failures?
Slip - correct plan is made but then executed incorrectly.
Lapse - correct plan is made but part of it is omitted or forgotten.
Violation - individual knows the rule/plan but chooses not to follow it (without ill intent).
Mistake - Doing something incorrectly due to a lack of knowledge.
According to the accident causation model, what causes active failures?
Error-producing condition that arise at different levels within the system.
What does an near miss improvement tool include?
Period of time.
Total number of near misses.
Total number of prescriptions dispensed.
Near miss error %.
What - type, time, staffing level.
Why - what do the team think were contributing factors.
React - identify solutions and suggestions.
Review - reflect on action plan. Was it completed and/or successful?
What does the near miss error log include?
Date.
Time of day.
Staffing level.
Dispenser and checker.
Name and brand of drug.
Type of near miss.
Possible causes.
Things to remember.
Action taken.
Potential adverse effect.
Types of medication errors?
Prescribing errors - unintentional but significant reduction in the probability of the treatment given being timely and effective or an increased risk of harm compared with normal practice.
Dispensing errors - incorrect medication given to patient. Majority wrong medication or wrong dosage.
Preparation errors - errors in the final operations process. Items left out of bag, severe medication supply delays, wrong items in patients bag.
Administration errors - wrong route, poor counselling resulting in poor adherence.
Monitoring errors
What is the fishbone diagram used in risk management?
Used to identify causes of a problem.
6ish potential causes are written, then individual examples are branched from these.
Equipment, people, communication, individual factors, task, education, conditions, organisation.
What are some examples of LASA drugs?
Rosuvastatin and Rivaroxaban.
Pregabalin and Gabapentin.
Quetiapine and Quinine.
Amlodipine and amitryptiline.
What are the RPS error reporting standards?
- Open and honest.
- Report - local or national guidelines.
- Learn
- Share
- Act - change practice and use quality improvement tools.
- Review - review changes to practice with a specified system or tool/
What should you do in the case of a dispensing error?
- Inform patient ASAP.
- Rectify issue.
- Offer an apology.
- Let colleagues involved in the error know.
What are the GPhC 9 standards for pharmacists?
Provide person-centred care.
Work in partnership with others.
Communicate effectively.
Maintain, develop, and use professional knowledge and skills.
Use professional judgement.
Behave in a professional manner.
Respect and maintain the person’s confidentiality and privacy.
Speak up about concerns or issues.
Demonstrate leadership.
