Session 1 - Patient Safety

Question 1

What is an adverse event

Answer 1

injury caused by medical management that prolongs hospitalisation and/or produced disability

Question 2

What is a preventable event?

Answer 2

an adverse event that leads injury that results from healthcare which can be avoided given the current state of medical practice and knowledge

Question 3

How can we avoid preventable events? (human factors)

Answer 3

reduce reliance on memory, standardise processes, make things simple, make things visable, clear check list, review processes, reduce reliance on vigalance

Question 4

Why does stuff go wrong?

Answer 4

Over reliance on individual responsibility (humans make mistakes)
Often the system is to blame (understaffed, long working hours, lack of equipment, poor training)

Question 5

What is the difference between active and latent failures?

Answer 5

Active - stuff that occurs at the sharp end of practice i.e. patient being given the wrong dose
Latent - predisposing conditions which lead to a failure (make active failures more likely i.e. poor training

Question 6

Describe the swiss cheese model

Answer 6

Hazard or problem at different levels -> these hazards ‘line up’ -> problems at many different levels in the system predispose and adverse event

not the fault of the individual, there are multiple factors!

Question 7

5 main goals of clinical governance

Answer 7

• prevent premature death
• help people recover
• ensure a positive experience in health care
• treat patients in safe environment (prevent preventable adverse events)
• Enhance the quality of life in those with a long term condition

Question 8

What the the 7 ways in which the NHS has tried to implement clinical governance?

Answer 8

1. Standard setting - NICE guidelines on EBM
2. Commissioning - drive quality through contracts
3. Financial incentives - QoF (rewards for positive things e.g. patient experience
4. Disclosure - disclosure of information on patient experience
5. Registration
6. Audits - see future card
7. Professional regulations - having to prove you are fit to practice in order to register with the GMC

Question 9

Define a clinical audit

Answer 9

A quality improving process that seeks to improve patient care and outcomes through systematic review of care against criteria and them implementing change

Question 10

What are the components of a clinical audit

Answer 10

Set a standard -> measure current practise -> compare with standard ->implement a change -> reaudit

Question 11

What is clinical governance?

Answer 11

NHS being accountable
continuing to improve the quality and standards of its services
safeguarding high standards