HaDSoc Week 1 Flashcards
What is clinical governance?
A framework through which NHS organisations are accountable for continuously improving quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish
Describe evidence demonstrating problems of quality and safety in healthcare
Quality:
Variations in medical care/ provision of specific health services across the country - can suggest not everyone is getting the best (inequity) or right care (waste) e.g. Higher relative risk of diabetic amputation in various parts of the country compared to others, CCGs across the UK not following NICE guidelines on hip replacements, having inconsistent requirements or having no commissioning policy
Safety:
Evidence that worldwide incidence of adverse effects 9.2% with 43.5% of these being preventable and 7.4% being lethal
14.4% of surgery patients have an adverse event, 38% of which are preventable
5% of deaths in English acute care deemed preventable - mostly related to omissions of care
Sepsis kills 37000 people per year
Shipman
Staffordshire
Bristol heart babies
What is an adverse event?
An injury caused by medical management as opposed to underlying illness, which prolongs hospitalisation and/or leads to disability
Why are a lot of adverse events unavoidable?
Side effects of drugs which are producing more benefit than harm
Drug reaction that occurs in a patient prescribed the drug for first time (unknown allergy)
What is a preventable adverse event?
An adverse event that could be prevented given the current state of medical knowledge
Why have quality and safety become so important?
Evidence patients are receiving substandard care or being harmed
Evidence of variation in quality of care across country
Direct costs and legal costs of poor quality of care or patient harm
Policy imperatives
How do we define healthcare quality?
Safe - no needless death
Effective - no needless pain or suffering
Patient centred - focus on patient needs and priorities
Timely - no unwanted waiting
Efficient - no waste
Equitable - no one left out - give everyone with the same need the same care
Define equity
Giving everyone with the same needs the same care
Why does it matter that there are variations in healthcare?
Patients across England vary in the extent to which they receive high quality care and in access to care - inequitable
Inappropriate care is wasteful
Give some examples of preventable adverse events
Operations performed on wrong body part Retained objects Wrong dose/type of medication given Failure to rescue - vital signs deteriorate and aren't noticed Some kinds of infections
What is a never event?
A preventable adverse event where the evidence is so clear that they should never occur
What are the two main reasons that adverse events occur?
Poorly designed systems that dont take account of “human factors”
Culture and behaviour of people working in healthcare
What do we mean when we say the system is over-reliant on individual responsibility?
All humans make errors
Everyone is fallible - cognitive limitations, forgetful, when we are tired dont perform as well
Most medical practice is complex and uncertain which increases the likelihood of mistakes
Healthcare system compounds this complexity by providing inadequate training, long hours, ampoules that look the same, lack of checks, different approaches to doing the same thing in different places
Traditionally not been concerted efforts to make healthcare systems better
Blame the individual
But the best individuals can make mistakes
Personal effort is necessary but not sufficient to deliver safe care
Human responses to particular kinds of situations are highly predictable because they occur frequently and most people do them but for some reason they are not well anticipated in health care systems
So is it always the system that is to blame for unsafe practice?
No occasionally people are incompetent, careless, badly motivated, negligent
But system failures are often at fault - multiple contributions to an incident or failing of care, not enough or not the right defences built in
What were the findings of the research into clinical system safety issues?
On a day to day basis there are an awful lot of challenging inconveniences that healthcare staff are faced with
The staff are aware of these problems and they know how to deal with them
Develop work-arounds that work for the individual staff member
Easier than trying to redesign the system so that it works better
Encourage heroic, compensatory model - dependence on individual brilliance which is impossible all the time
Makes people rush and make mistakes
Mistakes get tolerated
Overall effect of degrading safety