Quality and Safety in Healthcare Flashcards
Why is quality and safety so important in healthcare?
To stop patients being harmed or receiving sub standard care
To stop variations in healthcare
For costs and legal bills
Define equity
Everyone with the same needs gets the same care
Is there equity in the NHS all across England?
No.
Many results show that there is an uneven amount of care given in England.
Care is inequitable in England
Describe some evidence that suggests an inequity in healthcare
You are twice as likely to have your foot amputated if you live in the southwest than if you live in the southeast
Most admissions to hospital with acute exacerbation of asthma are avoidable, yet 5-fold variation in admission rates across England
Define an adverse event
An injury that is cause by medical management (rather than the underlying disease) and that prolongs the hospitalisation, produces disability or both
Define preventable adverse event
An adverse event that could be prevented given the current state of medical knowledge.
Give an example of an unavoidable adverse effect
A drug reaction that occurs in a patient prescribed the drug for the first time.
Give some examples of adverse events that are avoidable
Operations performed on the wrong part of the body
Retained objects
Wrong dose/type of medication given
Failure to rescue
Some kinds of infections
Why do things go wrong in healthcare?
Poorly designed systems that do not take into account human factors
Culture and behaviour
How does an over-reliance on individual responsibility cause things to go wrong?
All human make errors - everyone of us is fallible
Most of medicine is complex and uncertain
Most errors result from the “system”
- Inadequate training
- Long hours
- Ampoules that look the same
- Lack of checks etc…
But healthcare has not traditionally tried to make itself safe - blamed individuals instead
Personal effort is necessary but not sufficient to deliver safe care
How could designs of system be better geared towards reducing human error?
Avoid reliance on memory Make things visible Review and simplify processes Standardize common processes and procedures Routinely use checklists Decrease the reliance on vigilance
Describe the Swiss cheese model
There is a route from a hazard to a loss, and to stop this you out barriers in the way, the more barriers you place the less hazards will get through and therefore reduce losses
Explain James Reason’s framework of error: active failures
Acts that lead directly to the patient being harmed
Occur at the sharp end of practise - closest to the patient
E.g. baby has seizures as a result of being given an overdose of a drug - The active failure was the administration of the wrong dose
Explain James Reason’s framework of error: latent conditions
Latent conditions are the predisposing conditions
Any aspect of context that means active failures are more likely to occur
- E.g. poor training, poor design of syringes etc…
Latent conditions can make it more likely that a baby could be given the wrong dose
So need defences that trap or mitigate the error
Give some examples of latent conditions
They can:
- be error provoking (time pressure, inexperience)
- create long lasting holes (unworkable procedures,
design deficiencies)
