Quality Improvement Flashcards
What is a systems approach to patient safety?
a set of elements (people, processes, information, hardware) that when combined have qualities that are not present in any of the elements themselves
a system is greater than the sum of its parts
What is the purpose of a root cause analysis?
provides a structured approach to the investigation of an adverse event, to try and identify the underlying factors (latent conditions) causing the problem(s)
What is a serious incident (SI) in healthcare?
events where the potential for learning is so great, or the consequences for patients/families are so significant, that they warrant a comprensive response
usually undertaken for NHS ‘never events’
What framework could be used to help undertake a root cause analysis and identify all the potential contributing factors?
Fish Bone Model
Some actions to resolve patinet safety issues are harder to implement but have a stronger and more effecitve impact; what types of factors are likely to be more effective?
Achitechtural Changes
(prepare cytotoxic medication away from non-cytotoxic)
Standardise Equipment
(standard RSI equipment)
Introduce Forcing Functions
(cannot Rx paracetamol witout weight on ePrescribing)
What information do healthcare RCA investigations commonly rely upon, that can result in them being of varying quality?
Medial Notes
Staff Interviews
Staff Statement
recall and hindsight bias
