HaDSoc Flashcards
What is an adverse event?
An injury caused by medical management (rather than the underlying disease) and that prolongs hospitalisation, produces a disability or both
Why has there been such a huge change in the quality and safety of health services recently?
Series of scandals- such as Bristol Enquiry (2001)
Emergence of lots of evidence indicating the patients are not safe or the services are not of a good quality:
- direct costs and legal bills –> inequitable care
- patients being harmed and receiving substandard care –> adverse events - unavoidable or preventable
- variations in h/c around the country –> not everyone is receiving the best care
What is an unavoidable adverse event?
Adverse event when the medical management had no reason to think the adverse event would occur and so are completely infallible (e.g. A drug reaction)
What is a preventable adverse event?
An adverse event that could be prevented given the current state of medical knowledge (e.g. Operations [never events], transfusion of blood to the wrong group! wrong dose of medication given, medication administered incorrectly)
What is a never event?
Events that should not happen under any circumstance
Why do medical errors happen?
INDIVIDUALS are at fault (incompetent, careless, badly motivated, negligent) Over reliance on individual responsibility - everyone is fallible, most medicine is complex or uncertain, personal effort is necessary but not sufficient to deliver safe care
SYSTEM is at fault (multiple contributions to an incident or failing of care and not the right defences built in) Most errors result from errors in the system - as they are poorly designed and don’t take into account human factors
General culture and behaviour
What is meant by human factors?
Factors that make a person human, which cannot be changed and which systems ought to try and account for, in order to avoid errors
- everyone is fallible, most of medicine is complex and uncertain, personal effort is necessary but not sufficient to deliver safe care
- many psychological responses to particular kinds of situations are highly predictable but often poorly anticipated
How can we remove human factors in order to reduce the incidence of medical error?
Avoid reliance on memory Make things visible Review and simplify processes Standardise common processes and procedures Routinely use checklists Decrease the reliance on vigilance
What are the three different types of error?
- Slips and lapses
- Mistakes
- Violation
What is meant by a slip/ lapse?
BY ACCIDENT
Error of action
Person knows what they are doing but action does not turn out as intended
What is meant by a mistake?
DIDN’T KNOW ENOUGH
Error of knowledge of planning
Action goes as planned but fails to achieve intended outcome because the wrong action was taken
What is meant by a VIOLATION?
INTENTIONAL ERROR
Intentional deviations from protocol, standards, safe operating procedures or other rules
What is equity?
Everyone with the same need gets the same care
What is inequitable care?
Patients across England vary in the extent to which they receive high quality care and in access to care
Why is equity not always the case?
Due to cost and legal bills
What is the Swiss cheese model of accident causation?
Successive layers of defences, barriers and safeguards in healthcare (layers of cheese) which hazards can penetrate through due to active failures and latent conditions/ failures (holes in the cheese) resulting in losses
What are active failures described in the Swiss cheese model of accident causation?
Acts that lead to direct harm of the patient, at the sharp end of practice closest to the patient
(E.g. Administering the wrong dose)
What are latent conditions/failures described by the Swiss cheese model of accident causation?
Predisposing conditions that make active failures more likely to occur
(E.g. Poor training, poor design of syringes, too few staff)
What is clinical governance?
A framework through which the NHS organisations are accountable for continuously improving the quality and safeguarding high standard of care by creating an environment in which excellence in clinical care will flourish
What are the NHS Outcomes framework and the 5 domain?
Specific national outcome goals and indicators in 5 domains linked to payments and financial incentives
1. Preventing people from dying prematurely
2. Enhancing quality of life for people with long term conditions
3. Helping people recover from episodes of ill health/ injury
4. Ensuring people have a positive experience of care
5. Treating and caring for people in a safe environment and protecting from avoidable harm
The NHS outcomes framework provides a national overview of how the NHS is performing, holds the health secretary and NHS CB accountable for £95 billion of public money and acts as a catalyst to change NHS culture and behaviour to drive up quality
In what 7 ways are quality and safety in NHS monitored and improved?
- Standard setting
- Commissioning
- Financial incentives
- Disclosure
- Regulation- registration and inspection
- Clinical audits
- Professional regulation
How is standard setting involved in monitoring and improving the NHS?
NICE quality standards- set of statements that are:
Markers of high quality, clinical and cost effective patient care across a pathway or clinical area that are:
- derived from the best available evidence such as NICE guidance or other NHS Evidence accredited sources
- produced collaboratively with the NHS and social care, along with their partners and service users
How is commissioning involved in monitoring and improving the NHS?
There are 211 clinical commissioning groups (CCG’s) in England
- commission services for their local populations
- drive local quality improvement through contracts
- held accountable for their progress in delivering outcomes by commissioning outcomes framework (COF) (use indicators that are shown to have a strong link with outcomes)
- COF indicators measure quality and (via NHS commissioning boards) hold CCG’s to account
How are financial incentives involved in monitoring and improving the NHS?
Quality and outcomes framework (QOF)
- sets national quality standards with indicators in primary care
- clinical organisational and patient experience
- general practices score points according to how well they perform against indicators
- practice payments are calculated based on points achieved (25% of GP practice income)
- results posted online (can compare GP practices to average for PCT and England)