19.07.06 Clinical governance and risk managment Flashcards
(28 cards)
What is clinical governance
A framework to ensure continuous quality improvement in health care. A quality assurance process, designed to ensure that standards of care are maintained and improved and that the NHS is accountable to the public.
7 points of clinical governance
- Patient/user experience and involvement
- Clinical risk management. Adverse events, complaints.
- Research and effectiveness. Evidence-based practice
- Information management. Patient data- accurate, up to date, confidential, secure.
- Education, training, CPD
- Clinical audit= review of clinical performance. EQAs. Performance vs agreed standards.
- Review of current practices against agreed standards (ensures best care is given to patients)
- Staff, staff management.
What is risk management
Systems in place to understand, monitor, minimise risks to patients and staff. To learn from mistakes and near misses.
How does risk management minimise risks to patients
- Identifies what has gone wrong
- Understand the factors that influence this
- Learning lessons from any adverse events
- Ensuring actions are implemented to prevent recurrence.
- Putting systems in place to reduce risks
What is a clinical incident
Any event which has (directly or indirectly) caused an adverse incident, error or user complaint or which may have a negative impact on patient care.
Steps after a clinical incident is identified
- Report event through adverse incident reporting systems.
- Immediate remedial actions defined and implemented.
- Investigation: likelihood of recurrence and severity of impact if an incident did occur
- Root cause analysis: systematic review of an incident identifying immediate (root causes) and underlying (contributing) factors associated when an incident occurs.
- Implement process designed to reduce risk and impact.
- Monitor and review.
- Promote blame-free culture. Will encourage everyone to report problems and mistakes.
What is a corrective action
Appropriate action taken to eliminate the root cause of a detected non-conformity or other undesirable situation and prevent reoccurrence.
What is a preventive action
Action take to eliminate the cause of a potential non conformity or other undesirable situation.
What is root cause analysis (RCA)
A systematic review of an incident identifying immediate (root causes) and underlying (contributing) factors associated when an incident occurs.
Three key attributes of clinical governance
- High standard of care
- Transparent responsibility and accountability for those standards
- Constant dynamic of improvement.
Who assumes legal responsibility for quality of care
- Trust boards (since 1999).
- Clinical governance is the mechanism by which that responsibility is discharged.
What is risk
The potential that a chosen action, inaction or activity will lead to an undesirable outcome.
List examples of risk management
Manual handling, COSHH assessments, prevention of infection, clinical risks
What is manual handling
Risk assessment of all procedures with potential manual handling. Done to protect staff and samples.
What is COSHH
Control of substances hazardous to health
What does COSHH assess
Risk of substances and procedures. Should be done prior to undertaking a procedure.
What percentage of patient contacts result in harm to patients or staff
10%. DoH 2000
-Half of these are preventable
Categories of adverse incident
- Adverse incident
- Patient safety incident
- ‘No Harm’ incident
- ‘Prevented’ incident
What is an adverse incident
-when an event occurs that causes harm to any person or damage/loss of property (Trust or individual). Includes near misses
Patient safety incident
Any unintended or unexpected incident that could have or did lead to harm for one or more persons receiving NHS funded healthcare.
‘No Harm’ incident
an unexpected or unintended incident which ran to completion but no harm, damage or loss occurred.
‘Prevented’ incident
any incident that had the potential to cause harm but was prevented from occurring, resulting in no harm, damage or loss.
What is the most common contributing factor to adverse incidents
Poor communication
What is RIDDOR
Reporting of injuries, diseases and dangerous occurrences regulations
