Clinical governance

Question 1

What are the 7 pillars of clinical governance?

Answer 1

• clinical audit
• clinical effectiveness
• risk management
• use of information
• education and training
• staffing/staff management
• client/carrier experience and involvement

Question 2

What are the different types of human error?

Answer 2

• slip ups
- eg selecting wrong strength tablet due to familiarity with routine
• cognitive
- eg memory lapse
• violations (not error as such)
- eg deviations from SOPs

Question 3

What are the four barriers to human error?

Answer 3

• Human action barriers
• Administrative barriers
• physical barriers
• natural barriers

Question 4

What are examples of physical barriers?

Answer 4

• locked drug cupboards
• high or low shelves
• warning stickers
• spilt certain drugs

Question 5

What are examples of physical barriers?

Answer 5

• locked drug cupboards
• high or low shelves
• warning stickers
• spilt certain drugs

Question 6

What are examples of natural barriers?

Answer 6

• ie distance, time, placement
• having a separate area of clinic, or clinic sessions for different activities
• leaving a gap of time when self checking ones own work

Question 7

What are examples of administrative barriers?

Answer 7

• standard operating procedures (SOPs)
• supervision and training

Question 8

What are examples of human action barriers?

Answer 8

• checking patients identities
• final prescription check

Question 9

What are the three ways you can learn from errors?

Answer 9

• individual level (self reflection)
• team/departmental level (from colleagues errors)
• organisational (from errors reported collectively)
• also learning from ‘near misses’