Safety and Quality Flashcards
Why is quality an safety important to consider for doctors?
Quality and safety are an important resposibility of doctors because: There is evidence that patients are being harmed or recieveing sub-standard care, there are variations in healthcare, direct costs and legal bill and policy imperatives of politics.
What are the 6 aspects of quality in healthcare?
Healthcare quality: safe – no needless deaths, effective – no needless pain or suffering, patient-centred – focus on patients’ needs and priorities, timey – no unwanted waiting, efficient – no waste and equitable – no one is left out.
Why is it important to consider equality of healthcare around the NHS?
Post code lottery for certain health care – change in relative risk for diabetic amputations depending on where you live – difference in management of diabetes also variations in liklihood to receive hip replacement.
What is equity?
Equity – everyone with the same need gets the same care – not the same as equality.
What is an adverse event?
Adverse event – an injury that is caused by medical management (rather than the underlying disease): that prolongs the hospitalisation or produces disability or both.
What is a preventable adverse event?
Preventable adverse event – an adverse event that could be prevented given the current state of medical knowledge.
What is a never event?
Something that should never occur in healthcare
Why do preventable adverse events occur?
Poorly designed systems that do not take acount of human factors and culture and behaviour.
Over reliance on individual responsibility - all humans make errors.
Fallible – cognitive limitations, forgetting things, tired and not performing well
Most medical practice is complex and uncertain
Usually it is failures of the system rather than an indiviudal themself – although that’s not impossible.
Why are many preventable adverse events preventable?
Often the mistakes made by individual are highly predictable – occuring frequently and in everyone. So they should be easily anticipated by the system and stopped by the system.
Give an example of diagnosing safety?
Diagnosing Safety – for prescription you need two pharmacists to have checked the drug and dosage before it can be signed off.
What is the difference between active failures and latent conditions that cause failure?
Active failures – wrong dose given
Latent conditions casuing the failure – poor trianing, poor design of syringes, too few staff or poor supervision.
What is the swiss cheese model for errors?
Swiss cheese model – error passed through many more holes before reaching the active failure at the end.
How can we fill these holes?
Avoid reliance on memory Make things visible Review and simplify processes Standardize common processes and procedures Routinely use checklists Decrease the reliance on Vigilance
What does the NHS do?
Clinical Governance – putting in place systems for monitoring and ensuring quality of care provided. Clinical governance means delivering on this duty – all doctors work under duties of clinical governance.
What is the definition of clinical governance?
Definition – a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standard of care by creating an environment in which excellence in clinical care will flourish.
