HaDSoc S1 - Quality & Safety Flashcards
Define a preventable event
An adverse event that could be prevented given the current state of medical knowledge
Define an adverse event
An injury caused my medical management (rather than the underlying disease) that prolongs hospital stay, causes disability or both.
How might an adverse event be unavoidable?
For example an adverse reaction to a drug is an adverse event but one that could not have been predicted or prevented
Give some examples of preventable adverse events
Operations performed on the wrong body part
Retained objects
Wrong dose/type of medication given
Why do adverse events occur?
Sometimes due to human error but mostly due to processes causing too much reliance on human factors
How could adverse event incidence be reduced?
Avoiding reliance on human factors: Avoid reliance on memory Make things visible Revise and simplify processes Standardise common processes and procedures Routinely use checklists Decrease the reliance on vigilance
What is the Swiss cheese model?
The idea that there are successive layers of procedures and safeguards to maintain patient safety, but there are holes in each layer caused by active failures and latent conditions.
In this model, sometimes all the holes can line up and harm comes to patients.
In the Swiss cheeses model, what are active failures?
Acts that directly lead to patient harm
Eg a baby has a seizure as a result of receiving an incorrect dosage of a drug
The active failure was the administration of the incorrect dose
In the Swiss cheese model, what are latent conditions?
Predisposing factors that increase the likelihood of active failures.
Eg, poor training, poor syringe design, too few staff, poor supervision.
Define clinical governance
A framework through which NHS organisations are accountable for constantly improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish
Give some NHS quality improvement mechanisms
Standard setting Commissioning Financial incentives Disclosure Regulation - registration and inspection Data gathering and feedback Clinical audit - local and national
Describe setting standards
Eg NICE guidelines
Users quality standards based on the best available evidence
Describe how commissioning improves quality of care
There are 211 clinical commissioning groups
They commission services for their local populations
They drive quality through contracts
How are financial incentives used to improve quality of care?
Can be used as an incentive or to penalise
For GPs, can be 25% of income
Key aspects of good care identified and used to reward GPs nationally
How does disclosure improve quality of care?
All trusts are required to annually and publicly publish reports on quality.
These focus on patient experience and safety
Therefore encourage trusts to improve to maintain their reputation
