Patient Safety Improvement Flashcards
Quality
- Service
- Product
- Environment
Quality improvement
Gap between what care is being given and what should be delivered
Gap Analysis
- Where are we now?
- Where would we like to be?
SMART aims
Specific Measurable Achievable Relevant/Realistic Time limited (for defined population)
PDSA cycle
Plan
Do
Study its effects
Act on what’s learnt
Outcome measures
Achieving an endpoint
Process measures
Measure of throughput
Balance measures
Checking change hasn’t caused a new problem
Incident reporting
- Collecting and analysing information about any event that could have harmed/did harm anyone
- A fundamental component of an organisation’s ability to learn from error (safe organisations have high reporting rates)
Adverse event iceberg
Serious errors - tip of iceberg Errors that could cause harm (unreported below) Errors considered insignificant Near misses = good catches Unnoticed errors
What should be reported?
- Drug errors
- Lost samples
- Hospital acquired infections
- Misdiagnosis
- Delay in treatment
- Pressure sores
- Poor communication
- Poor discharge arrangements
- Sharps/needlestick injuries
- Slips, trips, falls
- Theft
- Violence and aggression
- Breach in confidentiality
- Unavailability of hospital records
- Administrative errors
- Manual handling injuries
- Equipment failures
Clinical incident
Related to planning, organisation, delivery of care, treatment procedures e.g. delayed diagnosis, misinterpretation of test, equipment error
Patient incidents
Non treatment related e.g. slip, trip, fall
Security incidents
e.g. Theft of property, violence or aggression
Staff incidents
e.g. Slips, trips, verbal/physical abuse, exposure to hazardous substances
Information Governance incidences
Information is leaked
Hazard
Something that could cause harm
Risk
The likelihood an incident would occur and how bad the consequences would be
Calculating risk
Risk matrix
- multiply consequence score by the likelihood score
- based on actual harm from incident not potential harm
Near miss
- Harm event did not happen due to discovery and action/by chance
- Harm prevent but potential could still exist and needs to be managed
- ‘Good catches’
4-step process to manage clinical risk
- Identify the risk
- Assess the frequency and severity of the risk
- Reduce/eliminate the risk
- Determine costs
National Reporting and Learning System
- All NHS trusts report incidents to NRLS
- Set up in 2004
- Clinicians and safety experts analyse reports to identify common risks and opportunities to improve patient safety
- Provide healthcare organisations with feedback and guidance to improve patient safety
National Patient Safety Agency (NPSA)
- all spinal (intrathecal) bolus doses and lumbar puncture samples are performed using syringes, needles and other devices with connectors that cannot connect with intravenous Luer connectors
- all epidural, spinal (intrathecal) and regional infusions and boluses are performed with devices that use safer connectors that cannot connect with intravenous Luer connectors or intravenous infusion spikes (Part B)
Serious incident results in
- Unexpected/avoidable death
- Serious harm
- Prevents/threatens to prevent an organisation’s ability to continue to deliver healthcare services e.g. allegations of abuse
‘Never events’
- Wrong site surgery
- Retained instrument post-operation
- Wrong route administration of chemo
- Misplaced nasogastric feeding tube
- Entrapment in bed rails
- Transfusion of ABO-incompatible blood components
- In-hospital maternal death from postpartum haemorrhage after elective c-section
- Maladministration of potassium containing solution
Serious incident process
- Identify and respond
- Communicate to patient, HCPs
- Report
- Investigate using RCA process timely manner
- CCG review and respond
- Action plan - develop, agree and implement
- Disseminate learning
- Monitor
Root cause analysis
- React
- Record
- Respond
NEWS
0 - patient stable
1-4 - increase observations every 4 hours or more
5 or more/3 in one of physiological parameters - increase observations 2 hourly, check blood glucose, contact FY2
7 - 1 hourly
SBARR
Situation Background - what led to situation Assessment Recommendations Review/Response
