Quality & Safety Flashcards
How is healthcare quality defined?
No needless deaths (safe)
No needless pain/suffering (effective)
No helplessness in those served/serving (patient-centred)
No unwanted waiting (timely)
No waste (efficient)
No one left out (equitable - everyone in need gets the same care)
Give some examples of why quality & safety in the NHS become so important.
- evidence of patients being harmed/receiving sub-standard care e.g. Mid-Staffordshire
- variations in healthcare
- direct costs & legal bills
- policy imperatives
Define an adverse event.
Injury caused by medical management (rather than underlying disease) which prolongs hospitalisation, produces a disability, or both.
Can be preventable or unavoidable
What is a preventable adverse event? Give some examples.
Adverse event that could be prevented given the current state of medical knowledge.
e. g. operations on the wrong part of the body, retained objects, wrong dose/type of medication given, failure to rescue, some types of infections
note: most preventable adverse events related to quality of clinical monitoring of omissions of care
Define a ‘never event’. Give some examples.
Event that should not happen in any circumstance
e.g. foreign object left behind, wrong procedure, wrong site
In general, why do preventable adverse events occur?
Poorly designed systems which do not take human factors into account
Culture & behaviour e.g. complaints not addressed at Mid-Staffordshire hospital
Give some examples of factors how over-reliance on individual responsibility causes preventable adverse events.
- personal effort is necessary but not sufficient to deliver safe care
- healthcare systems more to blame for errors, including inadequate training, long hours, ampoules looking the same, lack of checks, etc.
- sometimes individuals are at fault (incompetent, careless, badly maintained, or negligent) but system failures are more often at fault (multiple contributions to preventable adverse events/incorrect defences built in)
Explain why poor anticipation of human factors causes preventable adverse events, and how these could be anticipated.
Many psychological responses to particular situations are highly predictable, but these are not anticipated in the healthcare system.
e.g. loss of situational awareness -> persist with wrong course of action
- avoid reliance on memory
- make things visible
- review & simplify processes
- standardise common procedures
- routinely use checklists
- decrease reliance on vigilance
Give some examples of how poor reliability of systems can cause preventable adverse events.
e.g. availability of equipment varies in theatres, patients lacking knowledge of relevant clinical information in outpatient clinics
Outline the Swiss Cheese Model (Reason’s framework of error).
Successive layers of defences, barriers, & safeguards between hazards and losses. Errors occur when all barriers are breached at once.
Some holes due to ACTIVE failures, some due to LATENT conditions
HAZARDS ————|———————|———-|———-> LOSSES
Active failures (sharp) = acts that lead directly to the patient being harmed e.g. administration of wrong dose of drug
Latent conditions (accidents waiting to happen) = predisposing conditions/any aspect of context that means active failures are more likely to occur e.g. poor training, poor design of syringes, too few staff, poor supervision ---> error provoking (time pressures, inexperience)/long-lasting holes (unworkable procedures/design deficiencies)
Give some examples of why the NHS was less safe in the past.
- focus on short term fixes
- encouraged heroic/compensatory model = fix errors when they occur instead of designing the system to prevent errors
- people required to rush —> make mistakes
- mistakes tolerated
Give some examples of why the NHS is safer in the present.
- standardise processes e.g. Formula 1 pit-stop
- improve teamwork
- system redesign based on human factors
Give two examples of laws passed in order to introduce programmes monitoring quality & improvement in the NHS.
1999: NHS trusts legally required to create systems for monitoring & ensuring quality of care provided
2012: Health & Social Care Act - Secretary of State for Health must try to secure continuous improvement in the quality of services with regards to effectiveness, safety, and quality of services (according to NICE standards)
What are the 5 domains of the NHS outcomes framework? How is it supposed to achieve this?
- Preventing people from dying prematurely
- Enhancing quality of life for people with long term conditions
- Helping people recover from episodes of ill health/injury
- Ensuring people have a positive experience of care
- Treating/caring for people in a safe environment and protecting them from avoidable harm
- provides national level overview of how well the NHS is performing
- holds Secretary of State for Health/NHS Commissioning Board accountable for ~£95bn of public money
- catalyses improvement in quality throughout the NHS by encouraging a change in culture/behaviour
What are the 7 different elements of NHS quality improvement mechanisms?
1) STANDARD SETTING
2) COMMISSIONING
3) FINANCIAL INCENTIVES
4) DISCLOSURE
5) REGISTRATION & INSPECTION
6) CLINICAL AUDIT
7) PROFESSIONAL REGULATION
