clinical governance Flashcards
(30 cards)
what is clinical governance
a framework that ensures healthcare providers are accountable for continuously improving the quality of their services and safeguarding high standards of care
why is clinical governance key for patient care
because it promotes a culture of continuous improvement, transparency, and accountability, ultimately leading to better patient outcomes and safety.
what does clinical governance involve
monitoring systems and processes to provide assurance of patient safety and quality of care across the organisation.
what tools can pharmacists use to ensure patient care
- digital technologies
- medication safety initiatives
- quality improvement programes
continuous professional development
audits, SOPs, CPD and patient feedback
National Patient Safety Agency (NPSA)
- swiss cheese model of accident causation
- some holes due to active failures eg. mistakes, procedural violations
- other holes due to latent conditions e.g. faulty equipment, lack of staff training
most common dispensing errors identified by community and hospital pharmacies
wrong drug, strength, form, or quantity, or labelling with the incorrect directions
factors that contributed to dispensing errors
look alike sound alike drugs
low staffing (so high workload and more interruptions)
computer software
inadequate lighting
community or hospital which has more errors?
community (0.1-3.32%)
hospital = 0.02-2.7
As in the case of Elizabeth Lee, previously pharmacists who were found guilty of section 64.1 or section 85.5 of what act could be convicted of a criminal offence
The Medicines Act 1968
what is section 64.1
supplying the wrong product to a patient
what is section 85.5
attaching the wrong label to a medicine
changes to it
- section 85.5 should now not be applied to which pharmacists
employed / self employed / locum ones
(so community i assume?) - Instead,the legal responsibility falls on the pharmacy owner or superintendent pharmacist
how has section 64 been changed? in 2018
- Community pharmacists + pharmacy techs now have a legal defence if the error was a genuine accident
- Medicine was dispensed at aregistered pharmacy
- It was done by aregistered pharmacist or tech(or someone under their supervision)
- The medicine was supplied for areal need(e.g. prescription or PGD)
- AND either:
- Theydidn’t knowthere was a problem with the medicine
- OR they realised the mistake and tried to fix it, anddidn’t know it was unsafe at the time
what about hospital pharmacists in regards to the changes in sections? who employs them?
typicallyemployed by the NHS, not by a pharmacy business under the Medicines Act framework, sothese rulings may not directly apply to them in the same way
What is clinical governance?
Clinical governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish.
what is clinical governance made up of
- Continuous Quality Improvement
- Excellence in clinical care
- Essential service
- Seven elements/framework
Elements of clinical governance……
- Patient and public involvement
- Clinical audit
- Risk management
- Clinical effectiveness programmes.
- Staff and staff management
- Education, training and continuing professional and personal development
- Use of information to support clinical governance and health care delivery
how are the elements split into diff sections
https://www.notion.so/dispensing-and-prescriptions-1dd00bb3982d806aa330f48dd45bc7bc?pvs=4#1e800bb3982d802ab017e81029ef6e1a
what is risk management about
minimising risks to patients
how do we do risk management?
- identifying what can and does go wrong during care
- understanding the factors that influence this
- learning lessons from any adverse events
- ensuring action is taken to prevent recurrence
- putting systems in place to reduce risks
key system to reduce risk of errors and ensure patient safety?
Standard Operating Procedures (SOPs) are essential to reducing the risk of errors and ensuring patient safety
what do clinical audits allow hcp to do
It allows healthcare professionals to compare their performance against a standard to see how they are doing and identify opportunities for improvement.
After this, changes can be made; followed by further audits to see if these changes have been successful.
what is a clinical audit?
In essence, clinical audit is a process by which pharmacists, doctors and other healthcare professionals can measure the quality of the care they offer.
clinical audit is used to monitor what
the day-to-day performance of a service or product against a known standard. It can be used for existing or planned services.
