Patient Safety and Quality in the NHS Flashcards

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1
Q

Why have quality and safety become so important?

A
  • Evidence of patient harm / sub-standard care
  • Variations in healthcare
  • Direct and indirect costs to the NHS
  • Government policies demanding change
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2
Q

Define healthcare quality from six different aspects

A
  • Safe – no needless deaths
  • Effective – no needless pain/suffering
  • Patient-centred – focus on patients’ needs & priorities
  • Timely – no unwanted waiting
  • Efficient – no waste
  • Equitable – no one left out
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3
Q

What variations in healthcare exist in the UK?

A

Patients across England vary in:

  • The extent to which they receive high quality care
  • Access to care
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4
Q

What is equity?

A

Equity: everyone with the same need gets the same care

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5
Q

What is an adverse event?

A

An adverse event is an injury caused by medical management (rather than the underlying disease) that prolongs the hospitalisation and/or produces a disability

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6
Q

Provide an example of an adverse event

A

A drug reaction that occurs in a patient prescribed the drug for the first time is an adverse event—but one that may be unavoidable

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7
Q

What is a preventable adverse event?

A

A preventable adverse event is an adverse event that could be prevented given the current state of medical knowledge

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8
Q

Provide some examples of preventable adverse events

A
  • Failure to rescue
  • Wrong dose/type of medication given
  • Retained objects
  • Operations performed on the wrong part of the body
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9
Q

Why do things go wrong in patient safety and quality?

A
  • Poorly designed systems that do not take account of ‘human factors’
  • Culture and behaviour
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10
Q

Most medical practice is complex and uncertain, thus increasing the likelihood of mistakes

Provide examples of how the healthcare system compounds this complexity

A
  • Inadequate training
  • Long hours
  • Similar ampoules with different contents
  • Lack of checks
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11
Q

In terms of James Reason’s framework of error, explain the principle of active failures

A
  • Active failures are acts which lead directly to the patient being harmed
  • They occur at the sharp end of practice i.e. by clinicians closely involved in care
  • E.g. baby has seizures as a result of being given an overdose of a drug*
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12
Q

In terms of James Reason’s framework of error, explain the principle of latent conditions

A
  • Latent conditions (or failures) are the predisposing conditions
  • It is any aspect of the context in which care is provided that means the active failures are more likely to occur
  • E.g. poor training, poor design of syringes, lack of checks*
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13
Q

Illustrate James Reason’s Swiss Cheese Model

A
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14
Q

Causes of safety issues in nhs

A

Fast paced - little time for team members to come together, not enough time for volume of patients Many experts and specialists - isolationism, large MDTs, many specialisations Continuity of care - community pharmacists Evolving hospital and community systems - multiple, changing systems

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15
Q

What is a Never Event

A

Serious, largely preventable should not occur if preventative measures in place

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16
Q

What type of incidents Require review under the Serious Incident Framework?

A

Never Events: Serious, largely preventable should not occur if preventative measures in place

17
Q

What is a patient safety incident

A

Patient Safety Incident An unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare

18
Q

Examples of never events

A

• Wrong site surgery • Wrong implant or prosthesis • Retained foreign object post-procedure • Medication • Mis-selection of a strong potassium solution • Administration of a medication through the wrong route • Overdose of insulin due to abbreviations or wrong administration • Overdoseofmethotrexatefornon-cancerpatients

19
Q

Defining healthcare quality

A
20
Q

What are human factors

A

Human factors encompasses all those factors that can influence people and their behaviour. In a work context, human factors are the environmental, organisational and job factors, and individual characteristics which influence behaviour at work.

21
Q

Human factors which can cause safety issues

A

• Loss of situational awareness • Perceptionandcognition • Teamwork/behaviours • Distractions • Mentalworkload • Device/productdesign • Physicalenvironment • Fatigue • Group effects / changes • Mentalwellbeing • Task complexity • Physicalworkload • Organisational factors / behaviours

22
Q

Cognition - attention mechanism

A

• Focusedattention • Dividedattention • Sustainedattention • Selective attention

23
Q

Situation awareness - red flags

A

• Disagreement between 2 sources of information • Fixation on a single task to exclusion of all else • Confusion or uncertainty not resolved • Failure to adhere to accepted practice • Failure to comply with warning signs • Failure to communicate effectively • Leading questions • Displacement activity • Something doesn’t feel right

24
Q

Factors which contribute to and event

A