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Year 2 - IDEALS > RCA > Flashcards

RCA Flashcards

1
Q

what is a RCA

A

systemic analysis of all the factors which predisposed to or had the potential to prevent an error

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2
Q

what are the basic principles of RCA

A

react record and respond

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3
Q

what are the 3 investigative tools for RCA

A

5 why’s

tabular timeline and fishbone analysis tool

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4
Q

what is PACE in infection control

A

probe
alert
challenge
emergency

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5
Q

describe how we can measure professionalism in a 360 form

A

peer rating model - performance evaluation - 11 responses provides sufficient reliability
1 is the worst and 8 is th best

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6
Q 
what do these mean 
adverse event 
significant event 
near miss 
serious incident
A

injury causing prolonged hospitalisation, disability or death by HC management

event significant in the care of patients or the conduct of practise

error with potential to cause adverse effect by fails to do so

never ever - unexpected or unavoidable death - threatens a HC team to continue services

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7
Q

what is the professional duty of candour

A

all clinicians must roper errors at early stage

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8
Q

what are the various types of incidents

A 
clinical - planning, organisation, treatment, 
patient - non-treatment related ie slip 
security - theft 
staff - slips, abuse 
information governance
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9
Q

describe the adverse event iceberg

A

tip = serious error and an error than could case harm

anything below is unreported such as insignificant, near misses and unnoticed

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10
Q

what is the role of clinical risk management

A

concerns with improving the quality and safety of HC services which have put patients in harm and acting to prevent them

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11
Q

describe the risk matrix score

A

consequence score 1-5 none to catastrophic

likelihood score - 1-5 - rare - almost certain

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12
Q

how do you calculate risk score

A

multiply the consequence score by the likelihood

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13
Q

what is a hazard vs a risk

A

hazard - ability to cause harm

risk - likelihood that incident would occur and how bad the consequence

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14
Q

give examples of serious incidents

A

wrong surgery site, chemo wrong route
never events
requires life saving treatment or permeant harm and threatens organisation to continue practice

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15
Q

what does the swiss cheese model help measure

A

active and latent failures

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16
Q

what models of error can measure contributory factors

A

organisational accidental model and fishbone model

17
Q

what is an active vs latent failure

A

active - cause immediate negative results - caused by individual

latent - scheduling problems - eg lack of resources and training

18
Q

what is required for an incident to be labelled a serious incident

A

2 directors need to agree

19
Q

what is the early warning score

A

NEWS - used for adults - need competent use

20
Q

describe the NEWS score

A

score 0 - patient stable
low score 0 - 4 = 4 hourly observations by nurse

medium score = 5 or 3 parameters in one group = 2 hour checks with nurse in charge

high score = immediate assess and review, hourly checks

21
Q

what is the SBARR model for communication

A 
S - situation 
b - background 
a - assessment 
r - recommendations 
r - review
22
Q

what are mortality indicators

A

shows if number of deaths over time will change and can compare

23
Q

what are three mortality indicators

A

crude mortality rate
hospital standardised mortality ration HSMR
summary hospital mortality indicator (SHMI)

24
Q

what is crude mortality rate

A

no deaths occurred divided by no admissions to health care providers in specified time interval (given as percentage)

25
Q

what is an issue with crude mortality rate

A

variation in quality of care between hospitals and variation in severity of cases

26
Q

what is HSMR

A

hospital standardise mortality rate - monitor death rates in a trust based on subset of diagnoses that give rise to 80% of in hospital deaths
national average is 100
expected number of deaths divided by actual no of deaths x 100

27
Q

what is variation in HSMR caused by

A 
check coding 
case mix
structure 
process
individuals and teams
28
Q

what is SHMI and when did it happen

A

summary hospital mortality indicator new 2011

products no of expected deaths expressed as ration of expected to actual deaths

29
Q

what is the difference between HSMR and SHMI

A

SHMI derived from all admission to secondary care organisation

30
Q

what is national average score of SHMI

A

1

31
Q

what is the Carlson index

A

5 factor standardisation

primary diagnosis, admission type, sex, age, comorbidities

Year 2 - IDEALS (6 decks)

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