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Flashcards in Clinical Governance and Risk Deck (10):

Seven Pillars of Clinical Governance

1. Patient and public involvement
2. Use of information to support clinical
governance and health care delivery
3. Risk management
4. Research and Clinical effectiveness
5. Clinical audit
6. Staffing and staff management
7. Education, training and continuing
personal and professional development


Risk management

• An aspect of clinical governance
• Defends the patient from unintended harm through medical procedures


Swiss cheese model of system failures

System safety relies on:
• Defences
• Barriers
• Safeguards

Barriers can be:
– Physical
– Natural
– Administrative
– Human action


Active failures

Unsafe act committed by the individual
• Slips – lack of attention
• Lapses – memory
• Mistakes – control but wrong plan of action
• Procedural violations – deliberate deviation


Latent failures

• More distant – failures in management or organisation
• Adverse effects
– Error or violation provoking
– Create weakness in defences


Physical barriers

• Things that physically prevent you from doing something
• Examples?


Natural barriers

• Barriers in time, distance, place
• Examples?


Administrative Barriers

• Paperwork and other administrative tasks
• Examples?


Human Action Barriers

• Actions taken by humans
• Examples?


Patient Safety Issues

• Lithium: affected by diuretics, change in salt conc - check levels
• Warfarin: ask for book
• Insulin: kept in a clear plastic bag to ensure patients has the correct type of insulin
• Controlled Drugs: Legally required to sign the back of prescription for schedule 2 and 3 but might not need to if you know the person collecting. Keep info confidential
• Methotrexate: Cytotoxic - should be kept separate. Dose is usually once weekly. 2.5mg should be the only strength you keep in the pharmacy, not 10mg
• Sulphonylureas: Used in diabetes, lowers blood glucose - should be kept separate
• Low Molecular Weight Heparins: Check dose and frequency and make sure patient knows how to use it