Safety And Quality Flashcards
Why is quality assurance in NHS important?
Evidence that pts are being harmed or receiving sub-standard care
Variations in healthcare (Postcode lottery - unfair)
Direct costs and legal bills - compensation etc
Policy imperatives
Define equity
Everyone with the same need gets the same care
To the NHS, what is an adverse event?
An injury that is caused by medical management (rather than the underlying disease) and that prolongs hospitalisation, produces a disability or both.
Give an example of an unavoidable adverse event
The side effects of chemotherapy treatment
What are “never events”?
Adverse events that should never happen as are extremely preventable
What makes human beings fallible?
Cognitive limitations
Forgetfulness
Getting tired
How does the health care system compound the problem of human fallibility?
Inadequate training Long hours Medications that look the same Lack of checks Different approaches in different hospitals
What are active failures?
Acts that lead directly to the patient being harmed
Occur at the ‘sharp end’ of practice
What are latent conditions in James Reason’s Framework of Error?
Predisposing conditions that mean active failures are more likely to occur
Eg. Poor training, poor design of syringe etc
Describe Reason’s Swiss Cheese Model
There are successive layers of defences, barriers and safeguards to prevent adverse events
The holes in these layers are due to latent conditions or active failures
When the holes ‘line up’ an error occurs
Name some of the many factors influencing safety
Pt characteristics Task Individuals Team Environment Department Hospital
How do we make systems safer?
Avoid reliance on memory Make things visible Review and simplify processes Standardise common procedures Routinely use checklists Decreased the reliance on vigilance
Define clinical governance
A framework through which NHS organisations are accountable for continuously improving the quality of their services and safe guarding high standards of care by creating an environment in which excellence in clinical care will flourish
Describe standard setting
NICE sets quality care standards based on best available evidence
Aim to define what high quality care should look like
Describe the Quality and Outcomes Framework (QOF)
Used in primary care
Sets national quality standards with indicators
GPs score ‘points’ according to how well they perform against the indicators
Payment based on points achieved
