Patient Safety And Quality In The NHS Flashcards
Give two reasons why quality and safety have become so important in the NHS.
Evidence that patients are being harmed
Monetary costs of legal/ insurances bills to the NHS
Mechanisms to improve care quality.
What is CQUIN?
What are freedom to speak up guardians?
Give an example of standard setting. Describe this.
Name 3 other mechanisms to improve care quality.
Making part of income conditional dependant on whether they demonstrate improvements in quality and innovation in specified areas of care
Deal with concerns of healthcare providers who have not followed good practice
NICE Quality Standards - set of standards developed for certain priority areas of care where there is often variation
- Gives information on how to improve quality and measure progress.
Realisation of doctors
Regulation and inspection (CQC)
Clinical audit
Feedback from patients - Friends and Family Test
Define adverse event.
Define preventable adverse event.
Give an example of an unavoidable adverse event.
An injury that is caused by medical care (not the disease itself) that prolongs hospitalisation, produces disability or both.
An adverse event that could be prevented given the current state of medical knowledge.
ADR in patient prescribed drug for the first time.
Give two ways in which the healthcare system itself increases chances of errors being made.
Long hours
Different approaches to doing the same thing in different places
Inadequate training
Ampoules look the same
According to James Reason’s framework of error what is the difference between an active and a latent failures.
What is the issue with this?
Active failure is the event that directly leads to harm occurring at the sharp end of practice usually by clinicians closely involved in care, who are USING the safety system. Latent failures/conditions are ones that predispose to this ie inadequate training, insufficient staffing and lack of checks or blocks built into work processes.
Active failures = more obvious than latent conditions and hence more blame lies on these people.
Describe the Swiss cheese model.
Layers represent layers of defence that have been established
Holes in the cheese = latent conditions (inevitable flaws that will lead to error) and active failures.
