Quality and Safety Flashcards
Do you appreciate that quality and safety are your responsibilities?
Yes.
Well done.
What evidence is there that NHS quality is not always optional?
There is geographical variation e.g. in diabetic foot amputation rates
Practice does not always match up to guidance = inequity
What are the components of good quality care?
Safe Effective Patient centred Timely Efficient Equitable
What is an adverse event?
Injury caused by medical management
What are the two types of adverse event?
Preventable e.g. WSS
Non-preventable e.g. primary reaction to a drug
What is James Reason’s Framework of Error?
Active failures result from latent conditions
e.g. wrong drug delivered as the drug ampules look the same
What is the Swiss Cheese Model?
There should be multiple layers of defence against errors
What are some human factors that should be taken into account to improve system safety?.
Avoid reliance on memory Make things easily visible Review + simplify procedures Standardise procedures Use checklists Don't rely on individual vigilence
What is clinical governence?
NHS organisations have a legal duty to put in place systems to monitor and improve quality and safety
Who sets clinical standards?
NICE
What are some examples of how quality is encouraged?
NICE standards
CCGs drive quality through contracts
Financial incentives e.g. QoFs
Disclosure i.e. publishing quality and safety info
Registration/inspection e.g. CQC, clinical audit
What are the components of the improvement cycle?
Study, act, plan, do
