Patient Saftey And Quality In The NHS Flashcards
Why have quality and safety become so important?
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
What things can be used to define healthcare quality?
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
How do we know that quality is not optimal?
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.
What things are shown to have particularly large variation in healthcare?
Amputations - the risk of limb amputations on diabetic people depending on where you are
Hip replacements - 3.8 fold variation between CCGs
Variations in healthcare
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
What mechanisms are used to improve care quality?
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
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”
What is a preventable adverse event?
“An adverse event that could be prevented given the current state of medical knowledge”
Are all adverse events avoidable?
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
What kind of avoidable events happen in surgery?
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
Why do things go wrong?
Poorly designed systems that do not take account of ‘human factors’
Culture and behaviour
Why is there over-reliance on individual responsibility?
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.
What is normally at fault when an error occurs, systems or individuals?
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)
Why are human factors important?
Because they are highly predicable
- They occur frequently
- Most people do them
But, these responses are often poorly anticipated.
There has traditionally been a failure to ensure organisational systems are designed to encourage safety. What has this resulted in?
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.