Patient Saftey And Quality In The NHS

Question 1

Why have quality and safety become so important?

Answer 1

Evidence that patients are being harmed or receiving substandard care.
Variations in healthcare
Direct costs and the legal / insurance bill to the NHS
Government policies that have demanded change

Question 2

What things can be used to define healthcare quality?

Answer 2

Safe - no needless deaths
Effective - No needless pain or suffering
Patient-centred - Focus on patients’ needs and priorities
Timely - No unwanted waiting
Efficient - No waste
Equitable - No one left out

Question 3

How do we know that quality is not optimal?

Answer 3

Variations in medical care suggest that not everyone is getting the best care - or the right care.

Variation in the provision of specific health services may sometimes be appropriate (because of variation in the needs of different populations) by can also suggest waste or inequity within the NHS.

Question 4

What things are shown to have particularly large variation in healthcare?

Answer 4

Amputations - the risk of limb amputations on diabetic people depending on where you are

Hip replacements - 3.8 fold variation between CCGs

Question 5

Variations in healthcare

Answer 5

The variations in healthcare have no clinical evidence.

Gaps exist between what is known to be effective and what happens in practise.

Patients across England vary in:
The extent to which they receive high quality care.
Access to care
So care is inequitable

Question 6

What mechanisms are used to improve care quality?

Answer 6

Standard setting - NICE quality standards

Commissioning to drive improvement - CCGs

Financial incentives -QOF, CQUIN

Disclosing information -Freedom to speak up guardians

Regulation and inspection - CQC

Clinical audit

Feedback from patients - Friends and family test

Revalidation of doctors

Question 7

What is an adverse event?

Answer 7

“An injury that is caused by medical management (rather than the underlying disease) and that prolongs the hospitalisation, produces a disability or both”

Question 8

What is a preventable adverse event?

Answer 8

“An adverse event that could be prevented given the current state of medical knowledge”

Question 9

Are all adverse events avoidable?

Answer 9

No, some are unavoidable. e.g. a drug reaction that occurs the first time a drug is prescribed.

But, some are preventable e.g operations on the wrong body part, retained objects, wrong dose / type meds, failure to rescue, infections

Question 10

What kind of avoidable events happen in surgery?

Answer 10

A major abuse of avoidable death and injury:

In US: 
4,000 "never events" each year
Foreign objects left behind 39x week.
Wrong procedure 20x week
Wrong surgery site 20x week

Question 11

Why do things go wrong?

Answer 11

Poorly designed systems that do not take account of ‘human factors’

Culture and behaviour

Question 12

Why is there over-reliance on individual responsibility?

Answer 12

Yes - all humans make errors.

Every one of us is fallible.

• We have cognitive liminations
• We forget things
• We get tired and don’t perform optimally.

Most medical practise is complex and uncertain which increase the likelihood of mistakes.

Personal effort is necessary but not sufficient to deliver safe care.

Question 13

What is normally at fault when an error occurs, systems or individuals?

Answer 13

Systems mostly - Often multiple contributions to an incident or failing of care.
Not enough or not the right ‘defences’ but in.

Sometimes individuals are at fault
-Occasionally people are incompetent, careless, badly motivated, negligent -even deliberately malign (Shipman)

Question 14

Why are human factors important?

Answer 14

Because they are highly predicable

• They occur frequently
• Most people do them

But, these responses are often poorly anticipated.

Question 15

There has traditionally been a failure to ensure organisational systems are designed to encourage safety. What has this resulted in?

Answer 15

Focus on short-term ‘workarounds’ rather than proper, durable fixes.

Tendency to rely on a heroic, compensatory model of individual brilliance that is impossible all the time, in place of systems that help individuals to work as wells possible.

The need for people to be vigilant at all times (in sub-optimal conditions) again, an impossible demand.

An overall tolerance for poor-quality care “bad things will happen..” and / or heaping blame only people when things really go wrong.

Question 16

What is James Reason’s framework of error (active failures)?

Answer 16

Acts that lead directly to the patient being harmed.

Occur at the sharp end of practise

• By clinicians involved in care
• Closest to the patient on the receiving end
• Visible

Question 17

What is James Reason;s framework of error (latent failures)?

Answer 17

Latent failures are the predisposing condition

-Any aspect of the context in which care is provided that means the active failures are more likely occur.

For example:
Poor training
Poor design of syringes
Lack of checks or blocks built into work processes
Too few staff
Poor supervision