Improving the quality & safety of care: Scandals, research & policy Flashcards
What did The Harvard Medical Practice Study (1991) find?
Nearly 4% of inpatients experience preventable harm, with 13% of these causing death
What did the Institute of Medicine report (1999) reveal?
It found that 44,000-98,000 preventable deaths occur each year in the US healthcare system.
What did the An Organisation with a Memory (2000) report estimate?
1 in 10 hospital experiences result in a safety incident, totaling 850,000 events per year costing £2bn.
What does the evidence suggest about patient harm?
Approximately 10% of hospital in-patients experience harm, with 10-13% resulting in death.
What is the estimated ranking of clinical harm as a cause of death?
Clinical harm is estimated to be the 4th leading source of death after heart disease and cancers.
What are the two issues highlighted in reports about patient harm?
Bad apples (individuals causing harm) and bad barrels (problematic systems enabling harm).
What are ‘bad apples’ in the context of patient harm?
Individuals who are malevolent, poorly trained, or past their best.
What are ‘bad barrels’ in the context of patient harm?
Systems that allow bad behavior to flourish and fail to exclude harmful individuals.
What is the old way of thinking about medical errors?
Errors and risks are inevitable features of medicine.
What is the new way of thinking about medical errors?
Mistakes and safety issues are rarely the fault of individuals or teams alone.
What are active errors?
Mistakes made at the sharp end of performance that immediately lead to harm.
What are latent errors?
Errors located upstream that influence individual performance and can lead to active errors.
What does the Swiss Cheese Model illustrate?
To prevent active errors, multiple layers of defenses are needed to block them.
What does the Root Causes Model in healthcare focus on?
It emphasizes addressing underlying organizational and management factors rather than individual mistakes.
What does Vincent’s framework highlight?
Different layers in the healthcare system that contribute to quality and safety.
What are quality and safety breaches often associated with?
Poor performance in clinical microsystems, incompetent professionals, and poor teamwork.
What are two immediate problems with individual blame in healthcare?
It discourages openness and neglects system factors.
What major events changed public perception of healthcare safety?
Incidents like Bristol Royal Infirmary, Harold Shipman, and Mid-Staffordshire.
What were the findings of the Bristol Royal Infirmary case?
29 babies died during cardiac procedures due to unchecked substandard performance.
What were the key recommendations from the Bristol Royal Infirmary report?
Increase patient safety concerns, involve patients in decisions, and enhance performance reviews.
What were the findings of the Harold Shipman case?
Dr. Shipman killed over 200 patients, leading to inquiries on regulation and governance.
What were the key findings of the Mid-Staffordshire Trust case?
Substandard performance and higher mortality rates due to prioritizing targets over safety.
What do inquiries aim to achieve?
Determine causes of events, allocate responsibility, and recommend changes to prevent recurrence.
What do inquiries reveal about healthcare systems?
They highlight regulatory failures, organizational goal displacement, and dysfunctional cultures.
