Quality And Safety Flashcards
What problems arise with quality and safety?
Patient and doctors view care differently
Variations in provision of services so inequitable
Define an adverse event
An injury caused by medical management that prolongs hospital care or leads to disability eg allergic reaction to drug
Define preventable event
An adverse event that could have been prevented using medical knowledge eg wrong dose
Define a never event
A preventable event that should not happen eg foreign object left behind
Why do problems occur with quality and safety?
Poorly designed systems
Human factors
Culture and behaviour
Complex and uncertain
What are the two theories of quality problems?
Human factors-system should expect errors so have defences
Swiss Cheese model-hazards gets through holes leading to losses. Holes are active failure or latent condition
Define active failure and latent condition
Active=acts that directly harm patient eg wrong drug
Latent=predisposing condition making active failure more likely eg poor training
How can systems be improved to reduce human factors?
Don't rely on memory Makes things visible Standardise common processes Use checklists Review and simply processes Learn from other industries Reduce need for vigilance
Define clinical governance
A compulsory framework through which NHS organisations are accountable for continuously improving quality of services and protecting high standards of care in environment where clinical excellence can flourish
What are the two main policies in this area?
Health and Social Care Act 2012
NHS Outcomes Framework
What are the five domains of the outcomes framework?
Prevent early death Increase QoL Help patients recover Positive care experience Safe environment
What are the seven quality improvement mechanisms of the outcomes framework?
Standard-setting Commissioning Financial incentives (best practice tariff, income based on achievement) Disclosure Registration and inspection Professional regulation Clinical audit
What six things should healthcare quality be?
Safe, effective, patient-centred, timely, efficient, equitable
