S1) Patient Safety and Quality in the NHS Flashcards Preview

(LUSUMA) Applied Social & Behavioural Healthcare Delivery Science II > S1) Patient Safety and Quality in the NHS > Flashcards

Flashcards in S1) Patient Safety and Quality in the NHS Deck (13)
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1
Q

Why have quality and safety become so important?

A
  • Evidence of patient harm / sub-standard care
  • Variations in healthcare
  • Direct and indirect costs to the NHS
  • Government policies demanding change
2
Q

Define healthcare quality from six different aspects

A
  • Safe – no needless deaths
  • Effective – no needless pain/suffering
  • Patient-centred – focus on patients’ needs & priorities
  • Timely – no unwanted waiting
  • Efficient – no waste
  • Equitable – no one left out
3
Q

What variations in healthcare exist in the UK?

A

Patients across England vary in:

  • The extent to which they receive high quality care
  • Access to care
4
Q

What is equity?

A

Equity: everyone with the same need gets the same care

5
Q

What is an adverse event?

A

An adverse event is an injury caused by medical management (rather than the underlying disease) that prolongs the hospitalisation and/or produces a disability

6
Q

Provide an example of an adverse event

A

A drug reaction that occurs in a patient prescribed the drug for the first time is an adverse event—but one that may be unavoidable

7
Q

What is a preventable adverse event?

A

A preventable adverse event is an adverse event that could be prevented given the current state of medical knowledge

8
Q

Provide some examples of preventable adverse events

A
  • Failure to rescue
  • Wrong dose/type of medication given
  • Retained objects
  • Operations performed on the wrong part of the body
9
Q

Why do things go wrong in patient safety and quality?

A
  • Poorly designed systems that do not take account of ‘human factors’
  • Culture and behaviour
10
Q

Most medical practice is complex and uncertain, thus increasing the likelihood of mistakes

Provide examples of how the healthcare system compounds this complexity

A
  • Inadequate training
  • Long hours
  • Similar ampoules with different contents
  • Lack of checks
11
Q

In terms of James Reason’s framework of error, explain the principle of active failures

A
  • Active failures are acts which lead directly to the patient being harmed
  • They occur at the sharp end of practice i.e. by clinicians closely involved in care
  • E.g. baby has seizures as a result of being given an overdose of a drug*
12
Q

In terms of James Reason’s framework of error, explain the principle of latent conditions

A
  • Latent conditions (or failures) are the predisposing conditions
  • It is any aspect of the context in which care is provided that means the active failures are more likely to occur
  • E.g. poor training, poor design of syringes, lack of checks*
13
Q

Illustrate James Reason’s Swiss Cheese Model

A