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
