First Do No Harm

Question 1

How is healthcare quality defined ?

Answer 1

Clinical effectiveness, safety and patient experience = forms the quality triangle

Institute of healthcare improvement defines it as - safety, effectiveness, patient centredness, timeliness, efficiency and equity

AKA safety is main factor in defining quality of healthcare

Question 2

What is patient safety according to WHO?

Answer 2

Absence of preventable harm to a patient during process of healthcare (HC) and reduction in risk of unnecessary harm associated with HC to an acceptable minimum

Question 3

The 2 ways to think of safety?

Answer 3

Safety I = absence of incidence = identify, monitor, log, and learn from incidents and their contributory factors

Safety II = The presence of best practice = learn from what goes well, capturing how and why things go right

Question 4

Why is safety important?

Answer 4

Unsafe HC = accounts more deaths than lung cancer, diabetes or road injuries

Question 5

Whatis the acronym used to remember the 6 domains of HC quality?

Answer 5

TEPEES

Timely
Effective
Patient-centred
Efficient 
Equitable
Safe

Question 6

What is the Bristol Heart Scandal?

Answer 6

High rates if infant deaths after cardiac surgery
Investigations found - problematic staffing, toxic leadership, a lax approach to safety, secrets about doctors’ performances and lack of monitoring

Question 7

What is the Morecombe Bay incident?

Answer 7

Unnecessary deaths at Furness General hospital - death of Joshua Ticombe in particular
Investigations found - medical recordings being intentionally destroyed, major wrongdoings, and threats of closure of the maternity ward

Question 8

What is the Mid-Staffordshire Scandal?

Answer 8

Concerning poor care and high mortality rates in patients at Stafford Hospital

Question 9

What 2 categories of factors contribute to ‘near miss’?

Answer 9

Human factors

Factors relating to the HC system

Question 10

What contributory factors influence clinical practice?

Answer 10

Patient factors - condition, language, communication, personality, social factors

Task and technology Factors - task design, clarity of structure, availability, use of protocols, accuracy of test results decision making aids

Individual (staff) Factors - knowledge and skills, competence, physical and mental health

Team Factors - communication (written and verbal),supervision, seeking help, team structure

Work Env. Factors - staffing levels and skills, workload, shift patterns, availability of maintenance equipment, management support

Organisational and Management Factors - financial resources, policies, standards, goals, safety culture, priorities

Institutional Context Factors - economics, regulatory contexts, NHS executives, links with external organisations

Question 11

What is the Swiss Cheese Model?

Answer 11

Considers both, system and human factors leading to incident = not just one individual’s fault

Triggers —-lead to—-> adverse effect

policies / procedures –> profession –> team –> individual –> environmental –> equipment

Combination of several latent failures lead to adverse event
Holes in swiss cheese = holes in barriers that act as latent failures in the system

Question 12

What are the major safety programmes and interventions that have been introduced in the last 2 decades?

Answer 12

1. The WHO Surgical Safety Checklist - 19 item tool to remove unwarranted variation from the surgical process to make double checks where things commonly go wrong
2. Incident Reporting - National Reporting and Learning System (NRLS) in the UK = national repository of all patient safety incidents reported across all providers in England
3. Safe Culture - emergence of interventions focused on safer culture

Question 13

What are human factor interventions?

Answer 13

Human factors = environmental, organisational and job factors = influence behaviour at work

Question 14

Who established the first clinical human factors group?

Answer 14

Martin Bromiley in 2007 - his wife died of anaesthetic accident

Question 15

What is the NHS dedicated Patient Safety Strategy and what does it involve?

Answer 15

UK national patient safety strategy = interventions based on insight, seeking workers for involvement and improvement

Patient Safety Collaboratives = groups situated within academia health science networks focused on delivering improvements in specific areas of patient safety

Patient Safety Transitional Research Centres = developing scientific evidence for interventions to improve patient safety

Question 16

What are further safety global initiatives?

Answer 16

WHO = dedicated team for patient safety

Imperial hosts one of WHO’s groups - Global Patient Safety Collaborative

Question 17

What is the heart of patient safety?

Answer 17

Patients and NHS staff who drive safety AKA PPIE (patient and public involvement)

Question 18

Summarise the NHS Patient Safety Strategy:

Answer 18

Insight = measurement, incident response, medical examiners, alerts, litigation = improve understanding on safety by drawing insight from multiple sources

Involvement = patient safety partners, curriculum and training, specialists, Safety II = people have skills and opportunity to improve patient safety throughout who system

Improvement - deterioration, spread, maternity, medication, mental health, older people, learning disability, antimicrobial resistance, research = improvement programmes enable effective and sustainable change in the most important areas

Question 19

Case Study:

Mr A = 95M
The clerking doctor used the medication history from a previous
admission (over a year ago). Amitriptyline 75mg as NIGHT was prescribed,
but this had been stopped by the GP months earlier. The patient received a
dose and the following morning was found to be extremely drowsy. Due
to Mr A’s age, he was very susceptible to many of the side-effects of this
medicine and had to spend an extra night in hospital.

What system and human factors contributed to this error?

Answer 19

System factors:

• What checks were in place to ensure Mr A was prescribed the correct medication in hospital
• Is it normal practice for the nursing home to send a copy of their drug chart to the hospital
• Was there an easy way for the A&E doctor to check e.g. contact of pharmacist, GP
• Was there any way for A&E to access GP records
• What checks were in place after the prescription was issued eg hospital pharmacist

Human factors

• clinician used discharge letter from last year = may have been more appropriate to use a more recent record, were they aware of where to get this information; was it a training issue or was it difficult for them to access the appropriate information

Question 20

How can an accurate, up-to-date medication history be obtained?

Answer 20

Prescribing tips include:

- Use reliable and recent sources to confirm a patient’s medication
- Where possible use at least 2 sources to get an accurate history. eg relative, pharmacist, GP
- When using medication lists, check the dates of prescribing for each medicine where available
- Work with Hospital and community pharmacists  to support your prescribing, and seek advice if you are not sure

Question 21

How can a framework be put in place for an intervention that can help avoid common mistakes?

Answer 21

PSDA cycle = Plan-Do-Study-Act cycle

Plan = objective, predictions, plan to carry out the cycle - who what where when
Plan for data collection

Do = carry out the plan, document observations, record data

Study = analyse data, compare results to predictions, summarise what was learnt

Act = what changes are to be made, next cycle?

Question 22

What is the QI (quality improvement) circle?

Answer 22

QI cycle =

1. Diagnose - assess area of organisation that requires improvement and generate baseline data
2. Plan and test - decide aims, methods, monitoring of change
3. Implement and embed - make any successes part of your systems or processes
4. Sustain and spread - consider how aims or intervention can continue to be implements, if appropriate, and how the conclusions can be made more widely available

Question 23

What can be used to ‘diagnose the quality’ of the problem data?

Answer 23

Use quantitative data - comparisons, benchmarking data, clinical audit data

Use qualitative data - adverse event analysis, complaints, service user feedback

Important to include data from patient’s perspective

Question 24

What is Action Research?

Answer 24

Another model of improvement - action research cycles =
Action describes, interprets, and explains social situations while executing a change intervention aimed at improvement and involvement

AKA understand patient and staff experience of a service