TO REVISE PUBLIC HEALTH Flashcards
1
Q
PREVENTION + SCREENING
What are the Wilson + Junger criteria for screening?
A
CONDITION
-important
- known natural history
- identifiable latent/pre-clinical phase
THE SCREENING TEST
- suitable (sensitive, specific, inexpensive)
- acceptable
ORGANISATION AND COSTS
- facilities
- costs and benefits
- ongoing process
THE TREATMENT
- effective
- agreed policy on whom to treat
2
Q
STUDY DESIGN
What are the advantages of a cross-sectional study?
A
- Relatively cheap + quick.
- Provide data on prevalence at a single point in time.
- Good for surveillance + public health planning.
- Large sample size.
3
Q
STUDY DESIGN
What are the disadvantages of a cross-sectional study?
A
- Risk of reverse causality.
- Cannot measure incidence as no time reference.
- Risk of recall bias + non-response.
4
Q
STUDY DESIGN
What are the advantages of a case control study?
A
- Quicker than cohort of intervention studies as it’s retrospective.
- Inexpensive, good for rare outcomes (e.g. cancer).
- Can investigate multiple exposures.
5
Q
STUDY DESIGN
What are the disadvantages of a case control study?
A
- Retrospective nature only shows an association (not causation).
- Difficulty finding controls to match with cases.
- Unreliable due to recall bias.
- Prone to selection + information bias.
6
Q
STUDY DESIGN
What are the advantages of a cohort study?
A
- Prospective so can show causation.
- Lower chance of selection + recall bias.
- Absolute, relative + attributable risks can be determined.
- Good for common + multiple outcomes.
7
Q
STUDY DESIGN
What are the disadvantages of a cohort study?
A
- Loss to follow-up, requires a control group to establish causation.
- Takes a long time, need a large sample size.
8
Q
STUDY DESIGN
What are the advantages of a randomised control trial?
A
- Can infer causality (gold standard).
- Randomisation allows confounding factors to be equally distributed + biases minimised (helped by blinding).
9
Q
STUDY DESIGN
What are the disadvantages of a randomised control trial?
A
- Is it ethical to withhold a treatment that is strongly believed to be effective?
- Time consuming, expensive.
- Volunteer bias – specific inclusion/exclusion criteria may mean the study population is different from typical pts (e.g. excluding very elderly pts).
10
Q
EPIDEMIOLOGY
Define bias.
A
A systematic deviation from the true estimation of the association between exposure + outcome.
I.e. systematic error > distortion of the true underlying association.
11
Q
EPIDEMIOLOGY
What is confounding?
What is the effect of confounding on a study?
A
Where a factor is associated with the exposure of interest + independently influences the outcome but does not lie on the causal pathway.
- May affect the validity of a study.
12
Q
EPIDEMIOLOGY
What is the Bradford-Hill criteria for assessing causality?
A
- Strength of association (the magnitude of the RR).
- Dose response (the higher the exposure, the higher the risk of disease).
- Consistency (similar results from different researches using various study designs).
- Temporality (does exposure precede outcome?)
- Reversibility (experiment) – removal of exposure reduces risk of disease).
- Biological plausibility (biological mechanisms explaining the link).
- Coherence (logical consistency with other information).
- Analogy (similarly with other established cause-effect relationships).
- Specificity (relationship specific to outcome of interest).
13
Q
EPIDEMIOLOGY
If association is not causal, how could it be explained?
A
- Bias.
- Chance.
- Confounding.
- Reverse causality.
- A true causal association.
14
Q
HEALTH DETERMINANTS ETC.
Define allostasis.
A
The stability through change, or homeostasis, of our physiological systems to adapt rapidly to change in environment.
15
Q
HEALTH DETERMINANTS ETC.
Define public health.
A
Defined as the science + art of preventing disease, prolonging life + promoting health through organised efforts of society.
- Population perspective – thinks in terms of groups, not individuals.
16
Q
HEALTH DETERMINANTS ETC.
What are the determinants of health?
A
PROGRESS
Place of residence
Race/ethnicity
Occupation
Gender
Religion
Education
Socioeconomic status
Social capital
17
Q
HEALTH DETERMINANTS ETC.
What are the 3 domains of public health?
A
- Health improvement.
- Health protection.
- Improving services.
18
Q
HEALTH DETERMINANTS ETC.
What are the different forms of health equity?
A
- Equal expenditure.
- Equal access.
- Equal utilisation.
- Equal healthcare outcome.
(All for equal need).
19
Q
HEALTH DETERMINANTS ETC.
What are the 2 main factors affecting health equity.
Give an example of each.
A
- SPATIAL INEQUITY (geographical) – infant mortality rates high in places like Africa but healthcare spending is low in these areas (health inequality + inequity).
- SOCIAL INEQUITY (age, gender, ethnicity, socioeconomic status etc) – socioeconomic inequity as angina Sx higher in more deprived areas but coronary artery revascularisations in those with angina Sx higher in more affluent areas in Sheffield.
20
Q
HEALTH DETERMINANTS ETC.
How is health equity examined?
A
- Supply/access/utilisation of healthcare.
- Healthcare outcomes.
- Health status.
- Resource allocation (health services or others like education, housing).
- Wider determinants of health.
21
Q
HEALTH DETERMINANTS ETC.
How is health equity assessed?
A
- Typically assess inequality, then decide if inequitable (inequalities need to be explained + equality ≠ equitable).
- Health care systems – equity often defined in terms of equal access for equal need (NHS) but measurement usually of utilisation, health status or supply.
22
Q
HEALTH PSYCHOLOGY
What is the main theory for explaining why people undertake health damaging behaviours?
A
Unrealistic optimism.
- Individuals continue practicing health damaging behaviours due to inaccurate perceptions of risk + susceptibility.
- They’re aware of risks but don’t think it would happen to them.
23
Q
HEALTH PSYCHOLOGY
In terms of unrealistic optimism, what are a person’s perceptions of risk influenced by mainly?
A
- Lack of personal experiences with the problem.
- Belief that it’s preventable by personal action.
- Belief that it’s not happened by now so it’s not likely to.
- Belief that the problem is infrequent.
24
Q
HEALTH PSYCHOLOGY
What other factors can influence a person’s perceptions of risk?
A
- Stress.
- Health beliefs.
- Cultural variability.
- Situational rationality.
25
HEALTH PSYCHOLOGY
What factors can affect compliance?
- Side effects of medications.
- Patient perception of risk.
- Socioeconomic status.
- Treatment for an asymptomatic condition (e.g. continuing Abx).
26
HEALTH PSYCHOLOGY
What is the NICE guidance on behaviour change?
- Planning interventions.
- Assessing the social context.
- Education + training.
- Individual, community + population-level interventions.
- Evaluating effectiveness + assessing cost-effectiveness.
27
HEALTH BELIEF MODEL
What is the Health Belief Model?
Behaviour change model that states individuals will change if they –
- PERCEIVED SUSCEPTIBILITY - Believe they are susceptible to the condition.
- SEVERITY - Believe that it has serious consequences.
- PERCEIVED BENEFITS - Believe that taking action reduces susceptibility.
- PERCEIVED BARRIERS - Believe that benefits of taking action outweigh costs.
28
HEALTH BELIEF MODEL
What can be added to the model to give more information about likelihood of action?
Give examples.
Cues to action.
- They can be internal or external + are not always necessary for behaviour change.
- Internal = increase pain, decrease ADLs.
- External = reminders in post, GP advice.
29
HEALTH BELIEF MODEL
What are the pros of this model?
- Can be applied to a wide variety of health behaviours.
- Cues to action are unique component to the model.
- Long standing model.
30
HEALTH BELIEF MODEL
What are the cons of this model?
- Does not differentiate between first time + repeat behaviour.
- Does not consider the influence of emotions + behaviour.
- Cues to action often missing.
- Alternative factors may predict health behaviour such as self-efficacy or outcome expectancy (whether they feel they will be healthier as a result).
31
THEORY OF PLANNED BEHAVIOUR
What is intention determined by in this model?
ASP
- ATTITUDE = a person's attitude to the behaviour (I don't think smoking is good).
- SUBJECTIVE NORMS = the perceived social pressure to undertake the behaviour (most people who are important to me want me to give up smoking).
- PERCEIVED BEHAVIOURAL CONTROL = a person's ability to perform the behaviour (I CAN give up smoking).
32
THEORY OF PLANNED BEHAVIOUR
What are the 5 points to bridging the intention-behaviour gap?
PPAIR –
- PERCEIVED CONTROL (something an individual feels they are capable of doing).
- PREPATORY ACTIONS (dividing task into sub-goals increases self-efficacy + satisfaction at the point of completion).
- ANTICIPATED REGRET (reflecting on feelings once failed, related to sustained intentions).
- IMPLEMENTATION OF INTENTIONS (biggest one, "if-then" plans – if I need to take my meds in the morning then I will place them here to remind me).
- RELEVANCE TO SELF (can they relate to the behaviour).
33
THEORY OF PLANNED BEHAVIOUR
What are the pros of this model?
- Can be applied to a wide variety of health behaviours.
- Useful for predicting intention.
- Takes into account importance of social pressures.
34
THEORY OF PLANNED BEHAVIOUR
What are the cons of this model?
- Lack of temporal element + direction or causality, no sense of how long behaviour change may take.
- 'Rational choice model' so doesn't take into account emotions.
- Assumes attitudes, subjective norms + perceived behavioural control can be measured.
- Relies on self-reported behaviour.
35
TRANSTHEORETICAL/STAGES OF CHANGE MODEL
What are the 5 stages?
PC PAM(R)
- PRECONTEMPLATION = no intention of stopping.
- CONTEMPATION - beginning to consider stopping, probably at some ill-defined time in the future.
- PREPARATION = getting ready to quit in near future, set stop date, go to Dr, throw away items (28d).
- ACTION = engaged in stopping behaviour on stop date (6m).
- MAINTENANCE = continues + engaged with abstinent behaviour (6m).
- RELAPSE can occur at any stage of the model.
36
TRANSTHEORETICAL/STAGES OF CHANGE MODEL
What are the pros of this model?
- Acknowledges individual stages of readiness (tailored interventions).
- Accounts for relapse/allows patient to move backwards in the stages.
- Gives temporal element (idea of timeframe/progression, albeit arbitrary).
37
TRANSTHEORETICAL/STAGES OF CHANGE MODEL
What are the cons of this model?
- Not all people move through every stage.
- Change might operate on a continuum rather than discreet changes.
- Does not take into account values, habits, culture, social, economic factors.
38
HEALTH PSYCHOLOGY
What are some other factors to consider that might influence behaviour change?
- Impact of personality traits on health behaviour (everyone responds differently).
- Assessment of risk perception.
- Impact of past behaviour/habit.
- Automatic influences on health behaviour.
- Predictors of maintenance of health behaviours.
- Social environment.
39
HEALTH PSYCHOLOGY
What do NICE mention about interventions for behaviour change?
- Should work in partnership with individuals, communities, organisations + populations.
- Population-level interventions may affect individuals + communities + vice versa.
40
HEALTH NEEDS AX
What is the essence of a HNA?
- Before a health intervention is done, a HNA must be done.
- It's a systematic method for reviewing the health issues facing a population, leading to agreed priorities + resource allocation that will improve health + reduce inequalities.
41
HEALTH NEEDS AX
What is the planning cycle in a HNA and how is this relevant to Doctors?
42
HEALTH NEEDS AX
Define need.
ability to benefit from an intervention.
43
HEALTH NEEDS AX
What are the 4 sociological perspectives of need?
FENC
- Felt need = individual perceptions of variation from normal health.
- Expressed need = individual seeks help to overcome variation in normal health (demand).
- Normative need = professional defines intervention appropriate for the expressed need.
- Comparative need = comparison between severity, range of interventions + cost.
44
HEALTH NEEDS AX
What are the 3 types of HNA?
- Epidemiological.
- Comparative.
- Corporate.
45
HEALTH NEEDS AX
Epidemiological HNA: what is the methodology?
- Defines the problem.
- Size of problem (incidence/prevalence).
- Services available (prevention, treatment, care).
- Evidence base (effectiveness + cost-effectiveness).
- Models of care (including quality + outcome measures).
- Existing services (unmet need, services not needed).
- Recommendations.
46
HEALTH NEEDS AX
Epidemiological HNA: what are the pros?
- Uses existing data.
- Provides data on disease incidence, mortality, morbidity.
- Can evaluate services by trends over time.
47
HEALTH NEEDS AX
Epidemiological HNA: what are the cons?
- Required data may not be available + variable data quality.
- Evidence base may be inadequate.
- Does not consider felt needs of people affected.
48
HEALTH NEEDS AX
Comparative HNA: what are the pros?
- Quick + cheap if data available.
- Indicates whether health or services provision is better/worse than comparable areas (gives a measure of relative performance).
49
HEALTH NEEDS AX
Comparative HNA: what are the cons?
- Data may not be available + variable data quality.
- May be difficult to find a comparable population.
- May not yield what the most appropriate level (e.g. of provision or utilisation) should be.
50
HEALTH NEEDS AX
Corporate HNA: what are the pros?
- Based on the felt + expressed needs of the population in question.
- Recognises the detailed knowledge + experience of those working within the population.
- Takes into account a wide range of views.
51
HEALTH NEEDS AX
Corporate HNA: what are the cons?
- Difficult to distinguish need from demand.
- Groups may have vested interests + may be influenced by political agendas.
- Dominant personalities may have undue influence.
52
HEALTH NEEDS AX
Give an example of a service that is demanded but not needed or supplied?
Cosmetic surgery.
53
EVALUATION OF SERVICES
What is meant by evaluation?
Evaluation is the assessment of whether a service achieves its objectives.
- Process that attempts to determine as systematically + objectively as possible the relevance, effectiveness + impact of activities in the light of their objectives.
54
EVALUATION OF SERVICES
What is the Donabedian framework and what do each headings mean?
- Structure – what is there.
- Process – what is done.
[Output sometimes included or classified under process].
- Outcome – classification of health outcomes.
55
EVALUATION OF SERVICES
Give some structure examples.
- Buildings = locations where screening is provided.
- Staff = number of vascular surgeons/1000 population.
- Equipment = number of ICU beds/1000 population.
56
EVALUATION OF SERVICES
Give some process examples.
- Number of patients seen in A&E.
- Number of operations performed (may be expressed as a rate).
57
EVALUATION OF SERVICES
Give some outcome examples.
5Ds:
- Death, disease, disability, discomfort, dissatisfaction.
Also:
- Mortality (e.g. 30-day mortality rate).
- Morbidity (e.g. complication rate).
- QOL/patient reported outcome measures (PROMS).
- Patient satisfaction.
58
EVALUATION OF SERVICES
Give some examples of PROMs used in outcome.
- Oxford hip score.
- Oxford knee score.
- Aberdeen varicose vein questionnaire.
- EQ-5D.
59
EVALUATION OF SERVICES
What are some issues with health outcome?
- Link (cause + effect) between health service provided + health outcome may be difficult to establish as many other factors may be involved (e.g. case-mix, severity, other confounding factors).
- Time lag between service provided + outcome may be long (e.g. healthy eating intervention in children + T2DM incidence in adults).
- Large sample sizes may be needed to detect statistically significant effects.
- Data may not be available or may be issues with data quality.
60
EVALUATION OF SERVICES
When considering data quality what should be considered?
CART
- Completeness.
- Accuracy.
- Relevance.
- Timeliness.
61
EVALUATION OF SERVICES
One aspect of evaluation is the quality of health services. What can be used when assessing this?
Maxwell's Dimensions of Quality (3As + 3Es) –
- ACCEPTABILITY (how acceptable is the service to the people needing it?)
- ACCESSABILITY (is the service provided?)
- APPROPRIATENESS (right treatment given to right people at right time?)
- EFFECTIVENESS (does the intervention/service produce the desired effect?)
- EFFICIENCY (is the output maximised for a given input or is the input minimised for a given level of output?)
- EQUITY (are patients being treated fairly?)
62
EVALUATION OF SERVICES
Give some examples of things to consider under...
i) accessibility.
ii) appropriateness.
i) Geographical access, cost to patients, waiting times.
ii) Overuse? Underuse? Misuse?
63
EVALUATION OF SERVICES
What are the 2 types of evaluation methods?
- Qualitative.
- Quantitative.
64
EVALUATION OF SERVICES
Describe qualitative evaluation methods.
- Consult relevant stakeholders as appropriate (e.g. staff, patients, relatives, carers, policy makers).
- Methodology = observation (participant vs. non-participant), interviews (unstructured, semi-structured or structured), focus groups, review of documents.
65
EVALUATION OF SERVICES
Describe quantitative evaluation methods.
- Routinely collected data (e.g. hospital admissions, mortality).
- Review of records (e.g. medical, administrative).
- Surveys, other special studies (using epidemiological methods).
66
FOOD + BEHAVIOUR
What are some factors promoting excessive energy intake?
- Employment (shift work).
- Characertistics of food (energy density, portion size).
- Social aspect (people usually go out for food).
- Genetics.
- Advertisements.
67
FOOD + BEHAVIOUR
Define malnutrition.
Refers to deficiencies, excesses or imbalances in a person's intake of energy and/or nutrients.
68
SOCIAL EXCLUSION
What are the 3 core principles of the NHS?
- Universal = it meets the needs of everyone.
- Comprehensive = it's based on clinical need, not ability to pay.
- Free = at the point of delivery.
69
SOCIAL EXCLUSION
What is the inverse care law?
The availability of medical care tends to vary inversely with the need of the population served.
- I.e. those who need it most, don't access it as much + vice versa.
70
SOCIAL EXCLUSION
What is meant by social exclusion?
The process of being shut out from any of the social, economic, political or cultural systems which determine the social integration of a person in society.
71
DOMESTIC ABUSE
What assessment tool can be used in domestic abuse?
Domestic Abuse + Sexual Harassment (DASH) tool.
- Encourages you to gather information about everything that is going on in the situation.
- No score that = high risk but may say something that suddenly makes you think they're high risk + need intervention.
72
MODELS OF BEHAVIOURAL CHANGE
Give 4 models of behavioural change?
Health Belief Model
Theory of Planned Behaviour
Transtheoretical model
motivational interviewing
73
SUBSTANCE MISUSE
What can I offer a newly presenting drug user?
Health check
Screening for blood borne viruses
Contraception, smear
Sexual Health Advice
Check general immunisation status
Sign post to additional help
Information on local drugs services, including needle exchange
74
SUBSTANCE MISUSE
What are the 3 levels of Basic Harm Reduction (as applied to drug users).
Action to prevent deaths
Action to prevent blood borne virus transmission
Referral where appropriate.
75
ALCOHOLISM
What is ‘hazardous drinking’?
Pattern of alcohol use which increases someone’s risk of harm
76
ALCOHOLISM
Describe the aetiology of problem drinking.
Individual
> genes / personality / physique
> occupation
> advertising / availability / peer group
Family
> Religion / tradition / culture
77
ALCOHOLISM
What does persistent drinking throughout pregnancy lead to?
Foetal Alcohol Syndrome
small, underweight babies; slack muscle tone
mental retardation; behavioural + speech problems
characteristic facial appearance
cardiac, renal + ocular abnormalities
78
ALCOHOLISM
What Public Health measures might be used to reduce alcohol usage?
Minimum price per unit of alcohol
Change licensing laws in areas where cirrhosis is the biggest problem
Reduce ‘passive drinking’ effects
79
ALCOHOLISM
What are the 4 questions which make up the CAGE questionnaire?
Have you ever thought you needed to CUT DOWN on your drinking?
Have you ever become ANGRY/ANNOYED at people criticising your drinking?
Do you ever feel GUILTY about your drinking?
Have you ever had an EYE-OPENER in the morning to ease your hangover?
80
ALCOHOLISM
How is Alcohol Dependence Syndrome classified?
Cluster of 3 of the below symptoms in a 12 month period:
Tolerance: increasing the amount of alcohol to achieve the same effect
Characteristic physiological withdrawal
Difficulty controlling onset, amount + termination of use
Neglect of social + other areas of life
Spending more time obtaining + using alcohol
Continued use, despite negative physical and psychological effects
81
ALCOHOLISM
Wernicke’s Encephalopathy is characterised by a triad of symptoms. Name these symptoms.
Acute mental confusion
Ataxia
Ophthalmoplegia
82
HEALTH NEEDS AX
What is felt need?
Felt need = individual perceptions of variation from normal health
83
HEALTH NEEDS AX
What is expressed need?
Expressed need = individual seeks help to overcome variation in normal health (demand).
84
HEALTH NEEDS AX
What is normative need?
Normative need = professional defines intervention appropriate for the expressed need.
85
HEALTH NEEDS AX
What is comparative need?
Comparative need = comparison between severity, range of interventions + cost.
86
HEALTH DETERMINANTS ETC.
what is vertical equity?
Unequal treatment for unequal need
(e.g. areas with poorer health may need higher expenditure on health services, common cold + pneumonia require different treatment).
87
HEALTH DETERMINANTS ETC.
what is horizontal equity?
Equal treatment for equal need
(e.g. pts with same disease should be treated equally).
88
HEALTH PSYCHOLOGY
What is health behaviour role?
- Health behaviour = a behaviour aimed to prevent disease (e.g. healthy eating).
89
HEALTH PSYCHOLOGY
What is the role of illness behaviour?
- Illness behaviour = a behaviour aimed to seek remedy (e.g. going to Dr/pharmacist).
90
HEALTH PSYCHOLOGY
What is sick role behaviour?
- Sick role behaviour = any activity aimed at getting well (e.g. resting, taking prescribed meds).
91
HEALTH NEEDS AX
Give an example of a service that is supplied + needed but not demanded?
Anti-hypertensives (as usually asymptomatic).
92
HEALTH NEEDS AX
Give an example of a service that is supplied but not needed or demanded?
>75 health check by GP as no benefit seen.
93
DEFINITIONS
Define salutogenesis.
Favourable physiological changes secondary to experience which promote healing + health.
94
RESOURCE ALLOCATION
What are the 3 ethical theories in context of resource allocation?
- Egalitarianism.
- Maximising/Utilitarianism.
- Libertarian.
95
RESOURCE ALLOCATION
What is the concept of egalitarianism?
- Provide all care that is necessary + required to everyone.
96
RESOURCE ALLOCATION
What are the pros/cons of egalitarianism?
Pros:
- equal for everyone (supports belief people deserve equal rights/opportunities)
Cons:
- economically restricted,
- tension between egalitarian aspirations + finite resources.
97
RESOURCE ALLOCATION
What is the concept of maximising/utilitarianism?
- Healthcare should be distributed to bring about the best possible outcome (criteria that maximises public utility).
98
RESOURCE ALLOCATION
What are the pros/cons of maximising/utilitarianism?
Pros:
- resources allocated to those most likely to receive most benefit.
Cons:
- those with 'less need' receive nothing.
99
RESOURCE ALLOCATION
What is the concept of libertarian?
Each individual is responsible for their own health, wellbeing + flourishment i.e. incentives for behaviour change, screening participation paid (all paid with savings made from better health outcomes).
100
RESOURCE ALLOCATION
What are the pros/cons of libertarianism?
Pros:
- onus on pt therefore may be more engaged.
Cons:
- not all diseases are self-inflicted,
- should people be held accountable for their current/future health?
101
MEDICAL NEGLIGENCE
Define negligence
A breach of duty of care which results in damage.
- There is failure to take proper care over something.
102
MEDICAL NEGLIGENCE
What 2 tests can be used to decide if there was a breach in a duty of care?
- Bolam test = would a group of responsible doctors do the same?
- Bolitho test = would it be reasonable of them to do so?
103
MEDICAL NEGLIGENCE
What are 6 broad factors which contribute to negligence?
- System failure.
- Human factors.
- Judgement failure.
- Neglect.
- Poor performance.
- Misconduct.
104
ERROR
Define error?
A preventable event that can cause or lead to an unintended outcome.
105
ERROR
What are some different types of human (individual) errors?
- Omission (required action delayed/not taken).
- Commission (wrong action taken).
- Sequence (action taken in wrong order).
- Fixation (regular act so don't recognise if something goes wrong).
- Negligence (actions/omissions do not meet standard of an ordinary, skilled person).
106
ERROR
What are 4 broad classifications of errors?
- Intention.
- Action.
- Outcome.
- Context.
107
ERROR
What are 3 types of intention error?
- SKILL-BASED (action made is not what was intended i.e. performing well-known task>little attention>error if distracted).
- RULE-BASED (incorrect application of a rule/incorrect plan or course of action taken i.e. in emergencies).
- KNOWLEDGE-BASED (lack of knowledge in a certain situation.
108
ERROR
What are some red flags for errors?
- Anomalies.
- Broken communication, missing information or confusion.
- Departures from normal practice.
- Stress.
109
ERROR
What are the 10 types of basic error?
- Sloth.
- Fixation + loss of perspective.
- Communication breakdown.
- Poor team working.
- Playing the odds.
- Bravado + timidity.
- Ignorance.
- Mis-triage.
- Lack of skill.
- System error.
110
ERROR
Define a never event.
A serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented.
111
ERROR
What organisations must the hospital trust report never events to?
- National Reporting and Learning Systems (NRLS).
- CQC.
- Strategic Executive Information System (StEIS).
112
ERROR
What are the 2 perspectives on error?
- Person approach = focus on the individual at fault.
- System approach = focus on the working conditions/organisations at fault.
113
ERROR
What is the concept of the person approach to error?
- Looks at + blames an individual/group of individuals.
- States errors are the product of unpredictable mental processes (inattention, distraction, negligence).
- Focusses on the unsafe acts of people on the frontline.
114
ERROR
What are the cons with the person approach to error?
- Anticipation of blame promotes 'cover up' + need for a detailed analysis to prevent recurrence (retraining, discipline).
115
ERROR
What is the concept of the system approach to error?
- Adverse events are the products of many causal factors.
- The whole system has some kind of flaw at fault to blame.
- Adapt system to prevent recurrence (recognise errors + implement defences).
- Errors occur due to interaction between active failures + latent conditions.
116
ERROR
How can errors + harm be reduced?
- Simplification + standardisation of clinical processes.
- Checklists + aide memories (SBAR).
- Team training.
- Risk management programmes to remedy latent factors.
- Mechanisms to improve uptake of evidence-based Tx patterns.
117
ERROR
Explain the concept of the Swiss Cheese model
- An organisations defences against error are modelled as a series of barriers, represented as slices of cheese.
- The holes in the slices represent weaknesses in individual parts of the system.
- The holes are continually varying in size + position across the slices.
- System failure occurs when a hole in each slice momentarily aligns.
118
ERROR
What do the 3 buckets represent in the 3 bucket model?
Self, context + task.
119
ERROR
What is the concept of the three bucket model?
- Error evolves due to interaction between personal, environmental + physical factors as well as organisation – this tool can help stratify risk.
120
ERROR
Three bucket model – what comes under self?
- Level of knowledge (newly qualified, senior support available, unaware of current protocols).
- Level of skill (competence + experience).
- Level of expertise (confidence, automaticity, expectations/assumptions).
- Current capacity to do task (fatigue, stressors, illness, life events).
121
ERROR
Three bucket model – what comes under context?
- Equipment (maintenance, availability, usability, power sources).
- Physical environment (lighting, surfaces, noise, temperature).
- Workspace (working environment, handovers, layout).
- Team + support (leadership, trust, briefing + reflection).
- Organisation + Mx (communication, safety culture + reporting, workload).
122
ERROR
Three bucket model – what comes under task?
- Errors (omission, commission, fixation, sequence).
- Task complexity (calculations, double checking).
- Novel task (unfamiliar events, rare events, new ways of working).
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ETHICS
Define ethics.
system of moral principles + a branch of philosophy that defines what is good for individuals + society.
124
ETHICS
Define morality.
concerned with the distinction between good + evil or right + wrong.
125
ETHICS
What is the concept of Utilitarianism?
- An act is evaluated solely in terms of its consequences to maximise good + minimise harm.
126
ETHICS
What are the cons of utilitarianism?
treats minorities unfairly to promote majority happiness,
how do you define what is good?
127
ETHICS
What is the concept or virtue ethics?
- Focuses on the person who is acting – do they express good character?
- An act is only virtuous if the person is acting with the genuine intention of doing the right thing – are they integrating reason + emotion.
128
ETHICS
What are the 5 focal virtues that are acquired?
- DISCERNMENT (ability to judge well).
- CONSCIENTIOUSNESS (being thorough, careful + vigilant).
- COMPASSION (showing concern for others).
- TRUSTWORTHINESS (ability to be relied on).
- INTEGRITY (being honest + having good moral principles).
129
ETHICS
What are the cons of concept or virtue ethics?
- virtues are culture-specific + too broad for practical application,
- no focus on consequences i.e. compassion may lead to not telling harmful truth = lying.
130
ETHICS
What is the concept of deontology?
- Features of the act determines worthiness.
- Teaches that acts are right/wrong + people have a duty to act accordingly (treat others how you would like to be treated).
131
ETHICS
What are the cons of deontology?
consequences not looked at, duties can conflict.
132
ETHICS
What are categorical imperatives?
- Version of deontology.
- Categorical imperative is a rule that is true in all circumstances.
- Act in a way you would be willing it to become universal law.
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GMC DUTIES AS A DR
What are the 4 domains encompassing duties of a doctor?
1) Knowledge, skills + performance.
2) Safety + quality.
3) Communication, partnership + teamwork.
4) Maintaining trust.
134
DIVERSITY EDUCATION
Define culture.
a socially transmitted pattern of shared meanings by which people communicate, perpetuate + develop their knowledge + attitudes about life.
135
DIVERSITY EDUCATION
Define stereotypes.
generalisations about the 'typical' characteristics of members of a group.
136
DIVERSITY EDUCATION
What are some challenges + solutions concerning diversity in healthcare?
- Language barriers (longer appts, interpreters).
- Fasting + needs for medications (speak to religious leader ?exemption).
- Health beliefs such as different expectations in Dr/Pt relationship (paternalistic), Jehovah Witnesses' refusing blood (talk to pts + understand their beliefs, education).
- Expectations of healthcare system private vs. NHS (education).
- Taboos (i.e. sexual health in some cultures).
137
DIVERSITY EDUCATION
Define prejudice.
attitudes towards another person based solely on their membership of a group.
138
TEACHING SKILLS
What is Peyton's 4 step procedure for skill training?
- Trainer demonstrates without commentary./
- Trainer demonstrates with commentary.
- Learner talks through + trainer does.
- Learner talks through + does.
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TEACHING SKILLS
What are some critiques of Peyton's 4 step procedure?
- Insufficient time for learner to practice.
- Insufficient feedback.
- Lack of clarity + thoroughness.
140
TEACHING SKILLS
What is the tripartite model of types of learning?
- Surface.
- Strategic.
- Deep approach.
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TEACHING SKILLS
What is meant by surface?
- Fear of failure.
- Desire to complete a course.
- Learning by rote + focus on particular tasks.
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TEACHING SKILLS
What is meant by strategic?
- Desire to be successful.
- Leads to a patchy + variable understanding (well organised form of surface learning).
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TEACHING SKILLS
What is meant by deep approach?
- Intrinsic, vocational interest, person understanding.
- Making links across materials, search for deeper understanding of the material, look for general principles.
144
TEACHING SKILLS
What are 4 different types of learner?
- Theorist = complex situation, can question ideas, offered challenges.
- Activist = new experiences, extrovert, likes deep end, leads.
- Pragmatist = wants feedback, purpose, may like to copy.
- Reflector = watches others, reviews work, analyses, collects data.
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TEACHING SKILLS
What is Kolb's learning cycle?
- Conclusions from experience (theorist).
- Experience (activist).
- What can I do differently next time? (pragmatist).
- Review + reflect on experience (reflector).
146
TEACHING SKILLS
What is the dual process theory?
- Intuitive thinking with its irresistible combination of heuristics + biases, together with analytical thinking, using evidence-based medicine.
147
LEADERSHIP
What are the 5 leadership styles?
- Authoritarian.
- Participative.
- Delegative (Laissez-faire).
- Transactional.
- Transformational (inspirational).
148
LEADERSHIP
What are the pros/cons of authoritarian leadership?
Pros:
- consistent results,
- time spent on crucial decision reduced.
Cons:
- v strict,
- lack of staff creativity/innovation,
- lack of group input.
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LEADERSHIP
What are the pros/cons of transactional leadership?
Pros:
- staff motivation + productivity increased,
- reward system.
Cons:
- innovation/creativity minimised,
- less leaders created,
- seen as coercive.
150
LEADERSHIP
What are the pros/cons of transformational leadership?
Pros:
- high value on corporate vision,
- high morale for staff,
- not coercive.
Cons:
- leaders can deceive staff,
- may need consistent motivation/feedback.
151
LEADERSHIP
What leadership model is best suited for healthcare and why?
- Transformational.
- It places the needs of pts, carers + families at the centre of all work + people can intervene when necessary.
- I.e. speak up if risk to pt, continually improve system, talk to seniors if lack of skill, knowledge or resources.
152
LEADERSHIP
What are the pros/cons of participative leadership?
Pros:
- encourages staff creativity,
- increases staff motivation.
Cons:
- decisions may be time-consuming,
- poor decisions may be made.
153
LEADERSHIP
What are the pros/cons of delegative leadership?
Pros:
- environment of independence,
- experienced staff can offer experience.
Cons:
- downplays role of leader,
- leaders avoid leadership,
- staff may abuse.
