RCA Flashcards
what is a RCA
systemic analysis of all the factors which predisposed to or had the potential to prevent an error
what are the basic principles of RCA
react record and respond
what are the 3 investigative tools for RCA
5 why’s
tabular timeline and fishbone analysis tool
what is PACE in infection control
probe
alert
challenge
emergency
describe how we can measure professionalism in a 360 form
peer rating model - performance evaluation - 11 responses provides sufficient reliability
1 is the worst and 8 is th best
what do these mean adverse event significant event near miss serious incident
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
what is the professional duty of candour
all clinicians must roper errors at early stage
what are the various types of incidents
clinical - planning, organisation, treatment, patient - non-treatment related ie slip security - theft staff - slips, abuse information governance
describe the adverse event iceberg
tip = serious error and an error than could case harm
anything below is unreported such as insignificant, near misses and unnoticed
what is the role of clinical risk management
concerns with improving the quality and safety of HC services which have put patients in harm and acting to prevent them
describe the risk matrix score
consequence score 1-5 none to catastrophic
likelihood score - 1-5 - rare - almost certain
how do you calculate risk score
multiply the consequence score by the likelihood
what is a hazard vs a risk
hazard - ability to cause harm
risk - likelihood that incident would occur and how bad the consequence
give examples of serious incidents
wrong surgery site, chemo wrong route
never events
requires life saving treatment or permeant harm and threatens organisation to continue practice
what does the swiss cheese model help measure
active and latent failures
what models of error can measure contributory factors
organisational accidental model and fishbone model
what is an active vs latent failure
active - cause immediate negative results - caused by individual
latent - scheduling problems - eg lack of resources and training
what is required for an incident to be labelled a serious incident
2 directors need to agree
what is the early warning score
NEWS - used for adults - need competent use
describe the NEWS score
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
what is the SBARR model for communication
S - situation b - background a - assessment r - recommendations r - review
what are mortality indicators
shows if number of deaths over time will change and can compare
what are three mortality indicators
crude mortality rate
hospital standardised mortality ration HSMR
summary hospital mortality indicator (SHMI)
what is crude mortality rate
no deaths occurred divided by no admissions to health care providers in specified time interval (given as percentage)
what is an issue with crude mortality rate
variation in quality of care between hospitals and variation in severity of cases
what is HSMR
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
what is variation in HSMR caused by
check coding case mix structure process individuals and teams
what is SHMI and when did it happen
summary hospital mortality indicator new 2011
products no of expected deaths expressed as ration of expected to actual deaths
what is the difference between HSMR and SHMI
SHMI derived from all admission to secondary care organisation
what is national average score of SHMI
1
what is the Carlson index
5 factor standardisation
primary diagnosis, admission type, sex, age, comorbidities
