Patient Safety and Quality in the NHS Flashcards
What was true of the quality and safety of health services up until about 15 years ago?
Often poorly monitored and managed
What has changed the poor monitoring and management of health services?
A series of scandals and the emergence of heatlh research evidence about quality and safety
What do the NHS, doctors, and other healthcare professionals now aim to do?
Work together to assure the quality of services and safety of patients
Why is quality and safety important in healthcare?
- Evidence that patients are being harmed, or receiving sub-standard care
- There are variations in healthcare
- Direct costs and legal bills
- Polcy imperatives
What is meant by safe healthcare?
No needless deaths
What is meant by effective healthcare?
No needless pain or suffering
What is meant by patient-centered healthcare?
Focus on patients’ needs and priorities
What is meant by timely healthcare?
No unwanted waiting
What is meant by efficient healthcare?
No waste
What is meant by equitable healthcare?
No one is left out
Why do we known that quality in healthcare is not optimal?
Variations in medical care suggest that not everyone is getitng the best, or the right, care
Are variations in provision of specific health services ever appropriate?
They may be
What may variation in the provision of specific health services suggest?
Waste or inequity within the NHS
Give two examples of where there is variation in the provision of specific health services
- Variations in diabetes related amputations across the country
- Variations in hip replacements across the country
What % of CCGs did not follow NICE and clinical guidance on referral for hip replacement, or had no commissioning policy?
73%
What could lack of adherence to guidance on referral for hip replacement or commissioning policy lead to?
Too many or too few referrals
What % of CCGs required patients to be in various degrees of pain of immobility, or required patients to loose weight, before hip replacement surgery?
44%
What problematic gaps exist in healthcare?
What is known to be effective, and what happens in practice
Why is care in England inequitable?
Patients across England vary in the extent to which they recieve high quality care and in access to care
What is equity?
Where everyone with the same need gets the same care
What is an adverse event?
An injury that is caused by medical management, rather than the underlying disease, and that prolongs the hospitalisation, produces a disability, or both
Give an example of an adverse event that is unavoidable
A drug reaction that occurs in a patient prescribed that drug for the first time
What are preventable adverse events?
Adverse events that could have been prevented given the current state of medical knowledge
Give 5 examples of preventable adverse events
- Operations performed on the wrong part of the body
- Retained objects
- Wrong dose/type of medication given
- Failure to rescue
- Some kinds of infections
How many people does sepsis kill in the UK every year?
37,000
How much does the risk of death increase with every hour sepsis goes untreated?
8%
What is the worldwide incidence of adverse events?
9.2%
What % of adverse events are lethal?
7.4%
What are most problems leading to adverse events related to?
Quality of clinical monitoring leading to omissions of care
What % of surgical patients have had an adverse event?
14.4%
What % of surgical adverse events may have been preventable?
Around 38%
How many ‘never events’ occur in the US each year?
4000
Give 3 examples of ‘never events’
- Foreign objects left behind
- Wrong procedure
- Wrong site
What are surgical adverse events a major cause of?
Avoidable death and injury
What theories are there as to why patient safety problems occur?
- Poorly designed systems that do not take into account ‘human factors’ - there is a over reliance on individual responsibility
- Culture and behaviour
- System failures often at fault
- Operational defects
- Failure to ensure organisations are geared to safety
Why do all humans make errors?
Everyone is fallible;
- All have cognitive limitations
- All forget things
- Get tired, and don’t perform as well as we can
What is the problem with most medical practice being complex and uncertain?
- Increases likelihood of mistakes
- Healthcare system often compounds complexity
In what ways do healthcare systems often compound complexity?
- Inadequate training
- Long hours
- Ampoules that look the same
- Lack of checks
- Different approaches to doing the same thing in different places
Traditionally, who is blamed when things go wrong in healthcare?
Individuals are blamed instead
What is the relationship between personal effort and delivery of safe care?
Personal effort is necessary, but not sufficient to delivery safe care
What is true of many human responses to particular kinds of situations?
They are highly predictable, occur frequently, and most people do them
What is the problem with predictable human responses in healthcare?
They are often poorly anticipated
When are individuals at fault in healthcare?
People can be;
- Incompetent
- Careless
- Badly motivated
- Negligent
Why may a healthcare system fail?
Not enough, or not the right, defences built in
What is the reliability of systems?
81-87%
What is the availability of equipment in theatres?
Ranges from 63 to 88%