Quality and Safety in Healthcare Flashcards
Define clinical governance
a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish
Why do quality and safety problems occur in healthcare?
poorly designed systems
not taking account of human errors
over reliance on individual responsibility
How do we know quality is not optimal?
variations in medical care
variations in the provision of specific health services
Outline an unavoidable adverse event
drug reaction, first time prescribed
Outline a preventable adverse event
Op on wrong part of the body
Incorrect dose given
Define active failures
acts that lead directly to the patient being harmed
e.g. a baby has a seizure as a result of being given an overdose of a drug
Define latent conditions
predisposing factors that mean active failures are more likely to occur
e.g. poor training, poor design of syringes, too few staff, poor supervision
What is the swiss cheese model?
illustrates that, although many layers of defense lie between hazards and accidents, there are flaws in each layer (active failures, latent conditions) that, if aligned, can allow the accident to occur
How can the swiss cheese model be used to improve patient safety?
knowledge of the model allows you to identify weaknesses and change then
“inserting additional layers of cheese into the system”,
What is first order problem solving?
do what it takes to continue patient care task, no more, no less
ask for help from people who are socially close rather than those who are best equipped to correct the problem (preserve reputation, avoid diff encounters)
What is second order problem solving?
When the action is successful to prevent the problem from recurring
Outline healthcare quality
SEE PET
Safe = no needless deaths Effective = no needless pain Efficient = no waste
Patient-centred = focus on needs and priorities Equitable = no one left out Timely = no unwanted waiting
Define an adverse effect
injury causes by medial management and that prolongs the hospitalisation, prod disability or both
How can we make healthcare safer?
avoid reliance on memory
make things visible
review and simplify processes
standardize common processes
checklists
