Clinical Governance and Risk

Question 1

Seven Pillars of Clinical Governance

Answer 1

1. Patient and public involvement
2. Use of information to support clinical
   governance and health care delivery
3. Risk management
4. Research and Clinical effectiveness
   programmes
5. Clinical audit
6. Staffing and staff management
7. Education, training and continuing
   personal and professional development

Question 2

Risk management

Answer 2

• An aspect of clinical governance

* Defends the patient from unintended harm through medical procedures

Question 3

Swiss cheese model of system failures

Answer 3

System safety relies on:
• Defences
• Barriers
• Safeguards

Barriers can be: 
– Physical
– Natural
– Administrative 
– Human action

Question 4

Active failures

Answer 4

Unsafe act committed by the individual
• Slips – lack of attention
• Lapses – memory
• Mistakes – control but wrong plan of action
• Procedural violations – deliberate deviation

Question 5

Latent failures

Answer 5

• More distant – failures in management or organisation
• Adverse effects
– Error or violation provoking
– Create weakness in defences

Question 6

Physical barriers

Answer 6

• Things that physically prevent you from doing something

* Examples?

Question 7

Natural barriers

Answer 7

• Barriers in time, distance, place

* Examples?

Question 8

Administrative Barriers

Answer 8

• Paperwork and other administrative tasks

* Examples?

Question 9

Human Action Barriers

Answer 9

• Actions taken by humans

* Examples?

Question 10

Patient Safety Issues

Answer 10

• Lithium: affected by diuretics, change in salt conc - check levels
• Warfarin: ask for book
• Insulin: kept in a clear plastic bag to ensure patients has the correct type of insulin
• Controlled Drugs: Legally required to sign the back of prescription for schedule 2 and 3 but might not need to if you know the person collecting. Keep info confidential
• Methotrexate: Cytotoxic - should be kept separate. Dose is usually once weekly. 2.5mg should be the only strength you keep in the pharmacy, not 10mg
• Sulphonylureas: Used in diabetes, lowers blood glucose - should be kept separate
• Low Molecular Weight Heparins: Check dose and frequency and make sure patient knows how to use it