Quality Control - Sem 4 Flashcards
Explain why there has been a focus on quality control in the NHS recently. (3)
Patients have been harmed or given substandard care.
Variations in healthcare exist across the country.
High legal / insurance bills relating to poor quality care.
Explain six characteristics of good quality healthcare. (6)
Safe - no needless deaths
Effective - no needless pain or suffering
Patient-centred - focused on the patients needs and priorities
Timely - no unwanted waiting
Efficient - no waste
Equitable - no one left out
Describe 4 methods that are in place to improve quality of care.
9 listed, name 4.
Use of standard setting - NICE guidelines
Use of commissioning - drive improvement through contracting.
Use of financial incentives - Quality Outcomes Framework gives better GPs more money.
Increased emphasis on disclosure - makes whistleblowing easier
Regular inspection - Public Health England.
Use of clinical audits
Feedback from patients
Revalidation of doctors every 5 years
Define an adverse effect. (3)
An adverse effect is an injury that is caused by medical management (rather than the underlying disease) and prolongs hospitalisation, produces a disability, or both.
Name one adverse effect that is unavoidable. (1)
An allergic drug reaction presenting for the first time.
Name four adverse effects that are avoidable. (4)
Operations performed on the wrong patient or the wrong site.
Retained objects like surgical swabs.
Wrong dose or type of medication given
Some infections eg line infections.
Name six things that can increase the occurrence of human error. (6)
I’M SAFE Illness Medications Stress Alcohol / drugs Fatigue Eating and elimination
Give 6 examples of how the healthcare system can make human error more likely. (6)
Inadequate training Understaffing Long hours Drugs that look the same Lack of checks in place Different ways of doing things in different places.
Explain the James Reason Framework of Errors. Give an example of each. (4)
Active failures are acts by the system that directly lead to the patient being harmed eg bab being given too much medication and having a seizure.
Latent failures are the predisposing conditions of the systems gat increase the likelihood of active failures eg bab is given too much drug and has a seizure because the nurses were understaffed and undertrained.
Describe three team events that assist in good team communication. (3)
Brief - initial meeting to assign roles and establish goals.
Huddle - when-needed meetings for problem solving, raising concerns and adjusting the plan.
Debrief - after action meetings to set up for the next brief, and highlight areas for improvement.
Describe five features of good feedback. (5)
Timely Respectful Specific Directed towards improvement Considerate
Describe the two challenge rule. (3)
This is a thing to do if you have been ignored when raising a concern. Challenge a second time, seek confirmation they acknowledge your concerns. If you’re still not happy, seek out a superior.
Describe the communication tool used for effective phone hangovers. (4)
SBAR
Situation - what is going on with the patient, who and where they are.
Background - patients clinical background and context of the call
Assessment - what I think the problem is
Recommendation - what I need to do next, and what I need from you.
Describe the communication tool used for effective and detailed hangovers. (10)
I PASS the BATON Introduction - your job, role Patient - name age sex location Assessment - chief complaint vitals diagnosis Situation - current concerns or changes Safety concerns - labs allergies fall risk Background - FHx PMHx medications Actions - taken and needed Timings - urgency Ownership - who is responsible Next - set up a plan and a backup.
Describe the four types of human error. (4)
Slips - failure of attention
Lapses - failure of memory
Mistakes - rule or knowledge based
Intentional violations
