Patient Safety Flashcards
what is HCAI
health care associated infection
when does HCAI occur
direct contact with health care setting or due to health care intervention eg medical or surgical treatment
what are some examples where HCAI can spread
catheter hospital acquired pneumonia cannulation sites C difficile MSSA MRSA norovirus
how many people are affected by HCAI and why is this a problem
300,000 a year which cost about 1bil per year
what are the 5 preventing steps to HCAI
hospital environmental hygiene hand hygiene use of PPE safe use and disposal of sharps principles of asepsis
what is Clostridum Difficile and why is it a problem
gram positive anaerobic bacterium
resist heat, light, and disinfectant
spread through contact or spores
found in gut flora and can survive long periods without host
can be asymptomatic, diarrhoea, toxic megacolon and death
what handling patients with suspected infectious diarrhoea what protocol is used
SIGHT
Suspect may be infective as no one reason for diarrhoea
Isolate patient to determine cause of diarrhoea
Gloves and aprons for contact
Hand washing before and after
Test stool for toxin
what is the most effective way to protect from HCAI
hand hygiene
where is most germs found on the hand and what’s the difference between men and women for hand washing
90% found under nails
20% women
40% men don’t wash hands after toilet
what is the yellow sign for isolation
patient is isolating due to infection
keep door closed
wash hands on entry and exit
what is route cause analysis
the systematic analysis of all factors which predisposed to or had potential to prevent harm or error
what are the 3 basic principles of RCA
react
record
respond
what are the 3 investigative tools for RCA
5 why’s - 5 why’s of what cause error
tabular timeline - all the events leading up to error in timeline form
fishbone analysis tool - listing all the factors such as task, communication, team, social, working condition to combine into why error occurred
when we are challenging poor infection control what is development of culture of healthy challenge
don’t be afraid to to challenge hygiene of people regardless of rank or stature
what does PACE mean in graded assertiveness
Probe - do you know that
Alert - can we reassess the situation
Challenge - please stop what you are doing
Emergency - STOP what you are doing
how do you measure professionalism
360 form or ramsey scale
peer rating model for evaluating performance of practicing physicians
need 11 responses of this from to provide reliability
what are the 4 types of error event in healthcare
adverse event - injury resulting in hospitalisation or death due to HC management
significant event - anyone in the team which causes significance in the care of patients
near miss - an error which had the potential to cause harm
serious incident - a never event, unexpected or avoidable death threatens to prevent further HC service
what is the professionalisms duty of candour
all clinicians must report errors at early stage so lessons can be learnt and patients protected from potential harm in the future
what are the 5 types of incidence
clinical incidence - relating to HC procedure
patient incident - slip/fall
security incident - theft
staff incident - verbal abuse or exposure to hazard
information governance incidents
what is clinical risk management
specifically concerns with improving the quality and safety of HCS’s that identify events that could put patients at risk
how does a risk matrix work
consequence score - 1 to 5 no sig harm to catastrophic
likelihood score - 1 to 5 - chance of happening rare to almost certain
these two score are multiplied together
what is a hazard
the ability of things to do harm
what is a risk
the likelihood that an incident would occur
define a serious incident such as never events
adverse effect such as wrong surgery site, chemo via wrong route which results in 1 of: death or staff patients or visitors, serious harm requiring life saving intervention, an event which threatens to prevent an organisation continuing HC
give examples of never events
wrong site surgery retained foreign object after procedure wrong implant misplaced gastric feeding tube scalding patients wrong drug route administration
if a serious event does occur what is the process of next steps
identify and reposed communicate to patient report do RCA in timely manner CCG review and respond action plan disseminate learning monitor
what is an active failure
cause immediate negative results such as caused by an individual
what is a latent failure
scheduling problems ie lack of resources or training
for a serious adverse event to be labelled as such what must happen
2 directors need to agree upon severity of the incident
What is NEWS and what is it used for
National early warning score
measures physiological parameters to identify how urgent medical attention is needed
what do the scores mean in the NEWS score
0 = stable, minimum observations
0-4 = low, observe every 4 hours and monitor urine
5 overal or score of 3 in 1 section - nurse check every 2 hours, glucose, fluid balance
7+ immediate assessment
hourly checks, fluids, critical care
what parameters are in the NEWS score
rating 1-3 for each 0 = normal
RR (12-20) O2 sat (greater than 96) Supplemental O2 (no) temp (36.1-38) systolic BP (111-219) HR (51-90) Level of consciousness
