Quality and Safety in Healthcare

Question 1

What is clinical governance?

Answer 1

clinical governance describes the structures, processes and culture required to ensure the quality and safety of care provided, as well as looking for ways to continually improve it

Question 2

Give 3 factors that can help to determine if heathcare provision is of high quality

e.g. safe

Answer 2

Safe

Effective

Patient-Centres

Timely

Efficient

Equitable

Question 3

What is equity in healthcare?

Answer 3

everyone with the same need gets the same care

Question 4

What is an adverse event and what therefore, is a preventable adverse event?

Answer 4

Adverse Event

an injury that is caused by medical management which prolongs hospitaliation or produces a disability/harm

Preventable Adverse Event

adverse event that could be avoided given the current state of medical knowledge

Question 5

Give an example of an unavoidable adverse event

Answer 5

drug reaciton that occurs on first time

chemotherapy is associated with bone marow suppression which can predispose the individual to infections

Question 6

What are active failures when considering James Reason’s framework of error?

Provide an example

Answer 6

acts that lead directly to the patient being harmed

e.g. administration of the wrong dose of medication causing a seizure

Question 7

What are latent conditions (or failures) when considering James Reaon’s framework of error?

Provide 2 examples

Answer 7

predisposing conditions that mean the active failures are more likey to occur

e.g. poor training, poor desing of syringes, too few staff, ampoules look identical except name

Question 8

How can knowledge of the Swiss cheese model be useful for improving quality and safety in healthcare?

Answer 8

mutiple layers or checks in a system can reduce the potential for latent conditions lining up and leading to an active failure

e.g. second checking medicine doses when drawing up, nurses wearing tabbard when doing drug round to prevent being disturbed

Question 9

What is first order problem solving?

Answer 9

fixing only the immediate problem

often to allow the patient care task to continue

Question 10

What is second order problem solving?

Answer 10

preventing problems from reoccuring by changing the process, rather than just fixing the immediate issue

Question 11

How can you make processes safer in healthcare?

give 2 examples

Answer 11

1. Avoid reliance on memory
2. Simplofy processes
3. Use checklists
4. Standardise common processes and procedures