L06: Improving The Quality And Safety Of Care

Question 1

What is the 4th leading source of death after CVD and cancer

Answer 1

Patient harm

Question 2

What is the Bristol royal infirmary inquiry about

Answer 2

29 babies died during cardiac procedures in 1990s

Question 3

What does the Bristol royal infirmary report

Answer 3

The organisation was characterised by culture of secrecy
Lack of monitoring
Lack of transparency with the families

Question 4

What are the key recommendations from the bristol royal infirmary

Answer 4

Patients should be more involved in decision
More systematic and external forms of appraisal and performance review
More concern with patient safety

Question 5

Who is Harold shipman

Answer 5

A doctor that was scandaled for killing over 200 patients

Question 6

What does the shipman inquiry 5th report say

Answer 6

GMC priorities profession over patients

Question 7

What were the key recommendations in the shipman inquiry 5th report

Answer 7

Culture change
Better info exchange
More robust external and transparent forms of regulation

Question 8

What is the mid Staffordshire report about

Answer 8

Unsafe care and performance in the hospital

Question 9

What did the mid Staffordshire inquiry find

Answer 9

High mortality rates
Patients neglects
Poor trained staff
Priorities meeting targets rather than needs of patients

Question 10

What does inquires do

Answer 10

Determine causes of events 
Allocate responsibility and balsam 
Make recommendations 
Enable victims of patients to debate 
Relegitimation to say we have learnt and are doing something about it

Question 11

What do enquires show

Answer 11

Regulatory failure
Organisational goal displacement
Dysfunctional cultures
Unsafe behaviour

Question 12

What are bad apples

Answer 12

Bad people, indiviual who are intent to cause harm

Question 13

What are the characteristic of bad apples

Answer 13

Poorly trained

Are not keeping up with research

Question 14

What are bad barrels

Answer 14

Problem systems that people work in

Question 15

What do bad barrels enable bad able to do

Answer 15

Go worse instead of preventing it

Question 16

What were the key finding of the Francis report

Answer 16

• Patient left in soiled bed clothes for length periods
• no feeding
• water left out of reach
• no assisted toilet
• toilets unhygienic
• dignity and privacy denied

Question 17

What is a negative organisational culture

Answer 17

An organisation focused on business and meeting targets
Bullying and harassment for people that speak up
Self motivation amongst staff
Professional disengagement

Question 18

What were the 6 recommendations for the mid Staffordshire inquiry

Answer 18

Common values 
Fundamental standard
Speaking up
Compassionate 
Strong patient centred leadership 
Accurate and useful info

Question 19

What is an active error

Answer 19

Shape end of individual performance, decision making and cognition

Question 20

What is a latent error

Answer 20

Located upstream in the environment and influence how individuals perform by exacerbating active errors

Question 21

Therefore what is active errors about

Answer 21

Patient safety incident

Question 22

What are latent errors about

Answer 22

Poor design and procedures

Question 23

What does the Swiss cheese model represent

Answer 23

Active errors are due to latent conditions

Question 24

How is culture usually changed

Answer 24

Via incentives and disincentives

Question 25

What is the problem with implementing incentives and disincentives to change culture

Answer 25

It only puts meaning to the rewards and not in the behaviour it aims to produce

Question 26

How do we report to learn

Answer 26

1) gather info about the incidence of harm
2) determine what incidents are important
3) understand what the incident occurred
4) develop solutions that limit future incidents