Session 1 - Quality and safety

Question 1

What is an adverse event?

Answer 1

-An injury caused by medical management which prolongs hospitalisation, produces a disability or both and cannot be avoided eg vomiting after chemo

Question 2

What is a preventable adverse event?

Answer 2

-An adverse event that could have been prevented given current medical knowledge eg operations on wrong body part, wrong dose, failure to rescue

Question 3

What is failure to rescue?

Answer 3

-A missed deterioration in a patient which should not have happened eg missed sepsis

Question 4

How is it evident that there are problems with quality and safety within the NHS

Answer 4

• Direct evidence from patients being harmed or recieving substandard care
• Variations in provision of healthcare nationally shows that not everyone is recieving the same amount of care -> eg variation in diabetic leg amputations depending on location, are some people receiving unnecessary leg amputations

Question 5

Describe some ideas about why poor patient safety occurs

Answer 5

• Poorly designed systems which do not account for human error eg inadequate training, long hours, drugs with same packaging, different protocols between trusts
• Culture and behaviour doesnt allow whistle blowing or admission of clinical weaknesses
• Over-reliance on individual responsibilities as the individual gets blamed and not the system, system never changes

Question 6

What is James Reasons Framework of error (swiss cheese)

Answer 6

-Active failures (acts which lead to harm) and latent conditions (predisposing conditions which mean active failures are more likely to occur) align and break several layers of barrier defences and safe guarding eg identical packaging and administering the wrong medication

Question 7

Describe how a systems based approach can improve quality and safety

Answer 7

-Takes into account all factors which influence one another contributing to quality and safety eg hospital policies, patient characteristics, individual practitioner, work environment

Question 8

State how human error factors can be reduced

Answer 8

• Avoid reliance on memory -> use signs and stickers
• Make things visible
• Use checklists
• Standardise protocols
• Review and simplify procedures

Question 9

What is clinical governance?

Answer 9

-Legal duty to continuously monitor and improve quality, safety and effectiveness of services under the health and social care act 2012 which provides a framework through which NHS organisations are accountable

Question 10

Describe some NHS policies and organisations which encourage safety within the NHS

Answer 10

• Financial incentives which work by payments based on results eg QOFs and Tariffs
• Clinical audits
• Disclosure of organisational performance and individual performance
• Standard setting for quality care

Question 11

What is a QOF?

Answer 11

• Quality and Outcome framework used in primary care which set national quality standards
• Practices score points based on standards and receive payments based on this
• Results published online

Question 12

What is a tariff?

Answer 12

• A reward systems intended to provide consistent basis for comissioning services
• Treatments which use similar levels of resources are grouped together in healthcare resource groupings (HRGs) and are designed as a unit of currency determining equitable reimbursement of healthcare
• Longterm incentive as efficient trusts make more profit and inefficient trusts loose profit
• Never-event deems no payment

Question 13

Outline the steps in a clinical audit

Answer 13

1) Set standards (criteria and standards)
2) Measure current practice
3) Compare results with standards (1st evaluation)
4) Change practice (Implemant change)
5) Re-audit (2nd evaluation)

Question 14

What is care quality comission?

Answer 14

-An organisation which monitor quality (unannounced visits) and can impose conditions (warnings, fines, closure) if unsatisfied