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Non Clinical > Quality, Risk & Legal > Flashcards

Quality, Risk & Legal Flashcards

1
Q

Elements of Open Disclosure:

A
  • Statement of apology (include “sorry this has occurred”)
  • Factual account of events
  • Opportunity for family to relay THEIR experience of events (and ask questions)
  • Discussion of consequences (incl potential)
  • Explanation of steps to mitigate future risk
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2
Q

Approach to a complaint:

A
  • Ensure patient SAFE and COMFORTABLE
  • EXPRESS REGRET for their experience
  • Encourage a formal complaint (liaison)

Quality Assurance:
- GATHER INFO: patient account, staff account, medical records. Root Cause Analysis
- PLAN ACTION: staff education, discipline, protocol etc.
- FOLLOW UP:
—> With patient: written/ meeting
—> Audit actions

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3
Q

Avenues via which a patient might complain:

A

Direct to care staf
In-charge/ director
Patient Liason Officer
Hospital CEO
Health Minister
Health Care Complains Commissioner (Ombudsman)
AHPRA
Media

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4
Q

Quality Assurance Cycle:

A
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5
Q

Quality Standards:

A

Domains via which quality is assessed.

APEEES

Access: wait times, inpatient beds
Patient-centredness: complaints, patient satisfaction
Effectiveness: following best practice
Efficiency: cost-effectiveness, avoiding waste
Equity:
Safety: eg. PPE, hazards

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6
Q

Clinical Indicators:

A

Some measures of how well an ED is performing/ the quality of its care.

Used to ID areas for improvement, and for benchmarking.

eg.
Readmission rates
Wait times
Did Not Wait rates
Time in ED (4 hours), Time to inpatient bed
Time to analgesia
Follow up of missed xrays
Staff retention
Staff sick leave
etc.

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7
Q

Steps of Root Cause Analysis:

A
  • Define issue
  • Collect data
    –> Fact check
    –> Staff, departmental, systems, processess
  • Outline root causes + prioritise these
  • Plan for mitigation + implement
  • Audit
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8
Q

GENERAL APPROACH to dealing with a missed injury (or incident):

A

1- Manage patient
- Safety, symptomatic, plan
2- Open disclosure
- Apology, Facts, Pt POV, Consequences, Steps incl FU
3- Quality assurance
- Report, Root cause analysis
4- Documentation
5- Medicolegal
- eg. Coroner, AHPRA, Police
- NAI, guardianship

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9
Q

Reasons for DNW:

A

Waiting times
Competing interests at home
Problem resolved
Felt not urgent enough
Unpleasant waiting room
Alternative care arranged (eg. GP)
Not understanding triage/ perceived unfairness
etc.

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10
Q

High risk DNW:

A

ATSI
Psych
Drug affected
Referred to ED
Chest pain/ head injury

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11
Q

How to reduce DNW:

A

Shorter wait times
Early analgesia/ antiemetic
Liason in wait room
Specialty liason (eg. Aboriginal Health Worker)
Communication re triage system/ expected wait time

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12
Q

Approach to DAMA:

A

Full informed consent
Sign DAMA form
DOCUMENT
Risk mitigation (eg. PO antibiotics)
Safety net incl. follow up

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13
Q

Components of INFORMED consent (5):

A

Diagnosis and expected outcome
Proposed intervention (include costs)
Consequences of NOT
Risks
Alternative options

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14
Q

Components of VALID consent (4):

A

Patient has capacity
Informed
Specific to the context
Freely given

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15
Q

When is WRITTEN consent required over verbal?

A

Verbal consent is just as valid as written consent as long as it is DOCUMENTED

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16
Q

Capacity vs Competence:

A

Capacity = functional (what we do)

Competence = legal term

These are assumed present for adults and assumed absent for minors, unless proven otherwise.

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17
Q

What is required to deem someone to have capacity (4):

A

Understanding
–> Can repeat back info re treatment, risks, probabilities
Appreciation
–> Can weigh up, apply to own self + circumstances
Reasoning:
–> Can explain their reasoning process
Expression of a choice

Doesn’t need to be choice most would consider rational, but must be able to rationalise it.

18
Q

Capacity to consent in minors:

A

16 + can consent TO treatment (cannot refuse)

<16 can consent TO treatment, if Gillick competent or emancipated

19
Q

Gillick Competence:

A

Not appropriate for complex/ life-altering things

Consider:
- Maturity
- Expressed understanding
- Marital status (ie. emancipation)
- Independent living/ financially

20
Q

When/how can parental consent be overridden/ invalid?

A
  • Parent lacks capacity (eg. Intoxicated)
  • Alternative guardian exists (eg. Ward of state)
  • Other parent consents
  • NAI suspected
  • Death or significant permanent damage likely
  • Decision clearly not in patient’s best interest
  • Emergency Guardianship obtained
  • Hospital superintendent approves
21
Q

When is mandatory reporting for a patient required?

A

MANDATORY
- Child at risk
- Person without capacity at risk
- Firearms or criminal injuries involved
- Notifiable disease

NOT Mandatory
- Impaired drivers (contact licensing body, but cannot directly revoke)
- OH&S
- Domestic violence

22
Q

Which deaths must be coronial notifications?

A

PATIENT
Patient unknown
Child

DEATH
Cause unknown
Unexpected
Violent
Unnatural (murder, accident, poison etc.)
Suspicious

CIRCUMSTANCES
In custody
Related to healthcare/ lack of (eg. missed Dx)

23
Q

Mandatory reporting of practitioner to AHPRA (notifiable offences(:

A

Intoxicated on job
Deviation + from accepted practice
Sexual misconduct
Placing public at risk from undisclosed harmful health/ psych condition (eg. TB)

(Can also make voluntary ones)

24
Q

List 5 notifiable diseases:

A

Anthrax
Botulism
Chickenpox (VZV)
COVID
Any food/ waterborne:
–> Campylobacter, Shigella, Salmonella, Legionella etc.
Measles
Monypox
Rabies
Syphilis
Tetanus

Etc.

25
Q

Factors contributing to ‘risk’:

A

ENVIRONMENT
- Alarms, noises
- Crowded/bustling
- Frequent interruptions

PATIENT
- Undifferentiated Dx
- Vulnerable: NESB, ALOC, extremes of age
- Complaint: headache, abdo pain, chest pain

STAFF
- Rostering
- Fatigue
- Juniority
- Turnover
- Multiple handover

26
Q

Ways to mitigate risk:

A
  • Accreditation/ credentialling
  • Staff education
  • Formalised protocols (eg. PSA)
  • Safe rostering
    –> Hours, skill mix, breaks, night-day transitions
  • Quality improvement cycle:
    –> Monitor complaints, clinical indicators, remedy, restudy
  • Processes for monitoring/ remediating underperforming staff
  • Department design (eg. not echoey)
27
Q

Causes of ED overcrowding:

A
  • Access block
  • Patient surge
  • Understaffed or Junior staffing
  • Delays to investigations (CT broken), referral (junior awaiting permission), review, treatment (no Rroom for PSA)
  • Acuity/ complexity of presentations
  • ED size/ capacity and design
28
Q

Consequences of ED overcrowding:

A

PERFORMANCE INDICATORS
- Longer LOS
- Ramping (+reduced community access)
- DNW/ DAMA
- Complaints
- Suboptimal care (eg. no privacy, no monitoring)
- Medical error
- Staff burnout/ loss of retention

29
Q

Ways to improve access block/overcrowding/improve ED flow:

A

PREHOSPITAL
- Screening
- GP access
- Public health campaigns

DEPARTMENTAL
- Larger space, geography based care (eg. fast track)
- Redirection
—> Alternative services, or planned represent next day
- Waiting room nurse/ CIN
- Early senior decision maker
- Inpatient teams seeing directly, Interim management plans, direct SSU referral
- Protocolised team assembly (eg. trauma call)
- Protocolised management (eg. code stroke)
- Streamlined comms system
-

GREATER HOSPITAL
- Code yellow
- Urgent discharge
- Hold on electives
- Stand up extra spaces (eg. recovery as acute)

30
Q

Definition of access block:

A

LOS in ED of >8 hours, for someone admitted/ intended for admission
(or died, discharged)

due to inadequate IP bed/staff

31
Q

Factors contributing to access block:

A

+
Not enough beds
Not enough staff for beds
Competing elective admissions from community
Inefficient discharge

32
Q

What bed occupancy % would be required to alleviate access block?

A

85% bed occupancy would fix issue.

33
Q

Privacy Legislation:

A

The Privacy Act- 1988

  • ## Deidentified information is no longer ‘personal information’- ie. it can be used without patient’s consent
34
Q

When can you share personal/medical information without consent (privacy)?

A
  • Reasonably expected (eg. for specialist referral)
  • Patient unable to consent but can be reasonably assumed okay (eg. wife)
  • Minor
  • Direct patient safety (eg. medical Hx from GP for LOC pt)
  • Authorised by law (child abuse, notifiable disease)
  • Enforcement-related(eg. homicide threat)
  • Safety of genetic relative (eg. serious genetic condition)
  • Missing person

Just need to be able to reasonably defend/justify decision

35
Q

What is required to prove negligence?

A

1- A duty of care existed
2- This was breached by act or omission
3- Harm was incurred (incl. financial, distress)
4- Harm was due to the negligent act

”Failure to exercise reasonable to care avoid harm”

36
Q

Who is legally responsible for patients in the waiting room?

A

Once triaged, HOSPITAL is responsible.

No doctor is responsible until there is a doctor-patient interaction. Then a Duty of Care exists.

Level of interaction that constitutes a doctor-patient relationship’ ergo Duty of Care, is grey:
–> ie. writing panadol from flight deck- no. Viewing limb in WR- probably

Visitors, workers etc.- nobody is responsible. If they then collapse on the premises, the HOSPITAL has DOC, until a doctor commences interactions.

37
Q

Time Based Targets in ED (ACEM):

A
38
Q

High risk factors for adverse events in ED:

A

Handover times
Night shift
End of shift (fatigued doctor)

NESB
ALOC
Violent/ threatening patient
Elderly
Frequent presenter

Seen by only one doctor
Other acuity in department at time
High risk complaints: headache, abdo pain, chest pain

39
Q

Steps for teaching/guiding a junior doctor:

A

As per ACEM Curriculum. Key points:

Rapport
Establish prior knowledge
Explain with:
- Clear words
- Simple concepts
- Systematic approach
- Practical steps
Check understanding
Offer support
Check in after

40
Q

Performance management of underperforming junior doctor:

A

INTRO
- Warning shot (difficult chat)
- Reinforce chat is to support and guide, not be punitive
- Directly explain the concerns (be specific)

EXPLORE
- Ask for their perspective
- Verify/ correlate details of what happened (including background experience etc)
- Touch on all contributing factors (departmental, patient, personal life)

PLAN
- Education, credentialling etc.
- Other learning opportunities (eg. rotations)
- Graded reporting (as appropriate):
–> ED supervisor
–> JMO director
–> Hospital admin
–> AHPRA*
- Make a ’SMART’ goal
- Plan to meet again
- Offer support (PD leave, roster changes etc.)

41
Q

Approach to impaired colleague:

A
  • Upfront, state reason for meeting
    –> “I noticed that….. the nurse in charge observed….”
    –> “This is out of character. Is there anything else going on?”
    –> “I wanted to see if I can help”
  • Explore reasons/ stressors
  • Explicit SUICIDE/SAFETY CHECK
  • Explore supports + offer additional
    –> “The department will be able to support you with sick leave. There is a doctor’s support line on….”
  • MANDATORY REPORTING… can encourage to self-report.
  • Immediate actions
    –> “We will have to take you off the floor today”, sick leave
  • Statement of support, privacy + arrange follow up

Non Clinical (7 decks)

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