Law And Ethics- professionalism Flashcards
What are the SEVEN pillars of clinical governance?
Audit Clinical effectiveness Risk management Patient and public involvement Education, training Information management Staff management
What is clinical governance?
It provides a FRAMEWORK that NHS organisations can FOLLOW to continually improve the quality of their services.
It also enables them to achieve high standards of care, and create excellent clinical care.
What are the NPSA and NRLS and what are their aims?
National Patient Safety Agency
Aim to improve patient safety by reducing the risk of harm through error
National Reporting and Learning System
The NPSA’s central system for recording and collating data on medical harm.
It was established to enable learning from errors.
Patient safety alerts can be issued from this.
What is the definition of a Patient safety incident?
Any unintended incident that could have or did lead to harm for one or more people receiving NHS funded care
What are the other two types of patient safety incidents we can come across?
Patient safety incident (level of severity no harm) and incident that caused no harm but was not prevented
Patient safety incident (prevented) incident that had the potential to cause harm but was prevented
What is classed as moderate harm?
Any patient safety incident that resulted in a moderate increase in treatment which caused significant but not permanent harm, to one or more persons receiving NHS care
What is classed as low harm?
Any patient safety incident that required extra observation or minor treatment and caused minimal harm, to one or more persons receiving NHS funded care
What is a medication error?
An incidence where there has been an error in the process of prescribing, dispensing, preparing, administering, monitoring or providing medicines advice, regardless of whether any harm occured.
The national patient safety agency creates patient safety alerts. What are these?
When the National Reporting and learning system receiving a lot of reports of errors surrounding a particular medication, The NPSA will issue a document called a patient safety alert to doctors, nurses, pharmacists etc highlighting what they should do to reduce the chances of this error happening.
Eg with warfarin, insulin, lithium, opioids, injectables…
WHat is a Never event?
These are unacceptable and eminently preventable
They are largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.
A Couple of examples of never events?
Wrongly prepared High risk injectables.
Overdose of midazolam
Overdose of opioids
Wrong route of administration for cytotoxic medication
Inappropriate administration of methotrexate
Misidentification of patients!
What is an example of a Proactive Risk management technique?
Ie done before any errors have been done
Failure Modes Effects Analysis
FMEA
What is an example of a Reactive risk management technique? (I.e done after the errors been made)
Root cause analysis
Reactive as it’s done after the event: to find out what caused it.
What’s the definition of failure mode and effects analysis?
A systematic method of identifying and preventing process and product problems before they occur
Define root cause analysis?
A structured investigation, aims to find the true cause of a problem, and the action needed to stop it happening in future.
Should be undertaken on dispensing errors.
What factors does the fish bone diagram explore when analysing the problems for contributory factors in a route cause analysis?
Patient factors Individual factors Task factors Communication factors Team factors Education and training factors Equipment Working conditions factors Organisational and strategic factors
Reasons accident causation model:
What is a latent failure (latent conditions)?
refers to less apparent failures of organization or design that contributed to errors or allowed them to cause harm to patients.
Involves failures at an organisational and management level
Example: whereas the active failure in a particular adverse event may have been a mistake in programming an intravenous pump, a latent error might be that the institution uses multiple different types of infusion pumps, making programming errors more likely. It’s like an “error waiting to happen”
Reasons accident causation model:
What are the error producing conditions?
Patient factors Team factors Task factors Individual factors Work environment
Reasons accident causation model:
What are active failures?
These are the actual error that happens I.e that involves the patient. It can be a result of latent conditions. Active errors: Unsafe acts Slips Lapses Violations Knowledge based mistakes Rule based mistakes
