Quality Improvement

Question 1

Outline the burden of medical errors in healthcare cause?

Answer 1

12,000 avoidable hospital deaths a year

1. 4 million adverse errors
2. 1 billion in clinical litigation costs

Question 2

Outline the importance of incident reporting

Answer 2

learn from the mistake

prevent it from reoccurring

make the necessary changes

Question 3

What is the role of root cause analysis?

Answer 3

retrospective investigation of adverse events, focusing on identifying latent factors causing the problem

contributory factors framework
fishbone diagram
5 whys
timelines

Question 4

What is a serious event?

Answer 4

events in healthcare where the potential for learning is so great or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response.

Question 5

What is a systems approach?

Answer 5

elements (people, processes, info, organisations) that when combined have qualities that are not present in any of the elements themselves

greater than the sum of its parts

used in = incident investigations, improvement following

Question 6

What mechanisms are employed to improve quality in the NHS?

Answer 6

standard setting = NICE

commissioning = CCGs, drive quality through contracts

financial incentives = goals, to rewards and penalise

disclosure = of performance to public

regulation, registration, inspection = CQC

audit and clinical improvement = during junior Dr training