L06: Improving The Quality And Safety Of Care Flashcards
What is the 4th leading source of death after CVD and cancer
Patient harm
What is the Bristol royal infirmary inquiry about
29 babies died during cardiac procedures in 1990s
What does the Bristol royal infirmary report
The organisation was characterised by culture of secrecy
Lack of monitoring
Lack of transparency with the families
What are the key recommendations from the bristol royal infirmary
Patients should be more involved in decision
More systematic and external forms of appraisal and performance review
More concern with patient safety
Who is Harold shipman
A doctor that was scandaled for killing over 200 patients
What does the shipman inquiry 5th report say
GMC priorities profession over patients
What were the key recommendations in the shipman inquiry 5th report
Culture change
Better info exchange
More robust external and transparent forms of regulation
What is the mid Staffordshire report about
Unsafe care and performance in the hospital
What did the mid Staffordshire inquiry find
High mortality rates
Patients neglects
Poor trained staff
Priorities meeting targets rather than needs of patients
What does inquires do
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
What do enquires show
Regulatory failure
Organisational goal displacement
Dysfunctional cultures
Unsafe behaviour
What are bad apples
Bad people, indiviual who are intent to cause harm
What are the characteristic of bad apples
Poorly trained
Are not keeping up with research
What are bad barrels
Problem systems that people work in
What do bad barrels enable bad able to do
Go worse instead of preventing it
What were the key finding of the Francis report
- 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
What is a negative organisational culture
An organisation focused on business and meeting targets
Bullying and harassment for people that speak up
Self motivation amongst staff
Professional disengagement
What were the 6 recommendations for the mid Staffordshire inquiry
Common values Fundamental standard Speaking up Compassionate Strong patient centred leadership Accurate and useful info
What is an active error
Shape end of individual performance, decision making and cognition
What is a latent error
Located upstream in the environment and influence how individuals perform by exacerbating active errors
Therefore what is active errors about
Patient safety incident
What are latent errors about
Poor design and procedures
What does the Swiss cheese model represent
Active errors are due to latent conditions
How is culture usually changed
Via incentives and disincentives
What is the problem with implementing incentives and disincentives to change culture
It only puts meaning to the rewards and not in the behaviour it aims to produce
How do we report to learn
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
