Patient Safety and Quality Flashcards
Define ‘equity’
Everyone with the same needs gets the same care
Explain what clinical governance means
A framework through which NHS organisations are accountable for continuously improving the quality of care by creating an environment in which excellence can flourish. It is a statutory duty.
Define ‘inequitable care’
Variations in the extent to which patients receive access to health and high quality care
Define ‘adverse event’
An injury caused by medical management that prolongs hospitalisation, produces a disability or both
Give an example of an unavoidable adverse event
A drug reaction occurring in a patient prescribed that drug for the first time eg allergy to penicillin.
What are the three types of error?
Slips/lapse - right action chosen but incorrectly executed
Mistake - wrong action chosen but executed correctly
Violation - intentionally choosing the wrong action
What is the ‘Swiss cheese model’?
Every step in a process can have weaknesses that lead to failure. Some of these weaknesses may be latent and some may be active. When all these weaknesses occur at once (analogous to holes in Swiss cheese lining up) failure and accidents occur
With regards to the Swiss cheese model, define active failures and latent conditions
Active failure - the actual incident. Occur at the sharp end of practice close to the patient
Latent conditions - predisposing factors that make the active failure more likely to occur
What are the 5 domains of the NHS outcomes framework?
Preventing premature death Enhancing long term conditions Recovery from injury Positive experience of care Safety of environment
What does the quality and outcomes framework (QOF) do?
Sets national quality standards with regards to primary care. General practices score points according to how well they perform against indicators - how they achieve payments and income
What is a clinical audit?
A quality improvement process that seeks to improve patient care and outcomes through systematic review of criteria and the implementation of change.
What are the components to a clinical audit?
Setting standards Measure current practice Compare results with standard Change practice Re-audit
What are the world health organisations 6 points on human factors?
Avoid reliance on memory Make things visible Simplify and standardise the process Use checklists Decrease reliance on vigilance
