patient safety and clinical governance Flashcards
what is clinical governance
a framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish
what are the 7 pillars of clinical governance
clinical effectiveness, audit, risk management, patient and public involvement, education and training, information management, staff management
what is patient safety
the avoidance, prevention of adverse outcomes or injuries stemming from the process of healthcare
what is the goal that WHO has set out, what are the high domains, what are the 3 areas they’re trying to address
high risk situations including vulnerable patient groups and high risk medicines, poly pharmacy, transitions of care.
4 domains- patients and the public, medicines, healthcare professionals, systems and practices of medication
define patient safety incident
an intent ended or unexpected incident that could have or did lead to hard for one or more persons receiving NHS funded care
patient safety incident (prevented)
any patient safety incident that had the potential to cause harm but was prevented, resulting in no harm to patients receiving NHS funded healthcare
define no harm- impact prevented
any patient safety incident that had the potential to cause harm but was prevented resulting in no harm to patients receiving NHS funded care
define no harm- impact not prevented
any patient safety incident that ran to completion but no harm occurred to people received NHS funded care
define low harm
required extra observation or minor treatment and caused minimal harm
severe harm
resulted in permanent harm
what is a stage 1 NHS england alert
warning- warns organisation of emerging risk, can be issued very quickly once a new risk has been identified to allow rapid dissemination of info
what is stage 2 alert
resource- provision of resources, tools and learning materials to help mitigate risk identified in stage one
what is a stage 3 NHS alert
directive- organisations are required to confirm they have implemented specific actions or solutions to mitigate the risk
what’s serious incident framework
a serious incident requiring investigation is defined as an incident that occurred in relation to NHS funded services and care
what are never events
wholly preventable, where guidance of safety recommendations that provide strong systematic protective barriers are available at a national level and should have been implemented by all healthcare providers
eg wrong route of administration, overdose of methotrexate for non-cancer patient
what is FMEA failure mode and effects analysis
systematic method of identifying and preventing process and product problems before they occur
what is route cause analysis
a structured investigations that aims to identify the true cause of a problem and the actions necessary to eliminate
what is the process of route cause analysis
1) gathering information about an incident
2) mapping info
3) identifying problems
4) analysing problems for contributory factors
5) determining root causes
6) developing recommendations and implementing solutions
what is a route cause
earliest points at which action could have been taken to strengthen the system for enabled appropriate care to be delivered, avert the cause of the incident, significantly reduce its impact in the event of reoccurrence
