Flashcards in Quality Control - Sem 4 Deck (24)
Explain why there has been a focus on quality control in the NHS recently. (3)
Patients have been harmed or given substandard care.
Variations in healthcare exist across the country.
High legal / insurance bills relating to poor quality care.
Explain six characteristics of good quality healthcare. (6)
Safe - no needless deaths
Effective - no needless pain or suffering
Patient-centred - focused on the patients needs and priorities
Timely - no unwanted waiting
Efficient - no waste
Equitable - no one left out
Describe 4 methods that are in place to improve quality of care.
9 listed, name 4.
Use of standard setting - NICE guidelines
Use of commissioning - drive improvement through contracting.
Use of financial incentives - Quality Outcomes Framework gives better GPs more money.
Increased emphasis on disclosure - makes whistleblowing easier
Regular inspection - Public Health England.
Use of clinical audits
Feedback from patients
Revalidation of doctors every 5 years
Define an adverse effect. (3)
An adverse effect is an injury that is caused by medical management (rather than the underlying disease) and prolongs hospitalisation, produces a disability, or both.
Name one adverse effect that is unavoidable. (1)
An allergic drug reaction presenting for the first time.
Name four adverse effects that are avoidable. (4)
Operations performed on the wrong patient or the wrong site.
Retained objects like surgical swabs.
Wrong dose or type of medication given
Some infections eg line infections.
Name six things that can increase the occurrence of human error. (6)
Alcohol / drugs
Eating and elimination
Give 6 examples of how the healthcare system can make human error more likely. (6)
Drugs that look the same
Lack of checks in place
Different ways of doing things in different places.
Explain the James Reason Framework of Errors. Give an example of each. (4)
Active failures are acts by the system that directly lead to the patient being harmed eg bab being given too much medication and having a seizure.
Latent failures are the predisposing conditions of the systems gat increase the likelihood of active failures eg bab is given too much drug and has a seizure because the nurses were understaffed and undertrained.
Describe three team events that assist in good team communication. (3)
Brief - initial meeting to assign roles and establish goals.
Huddle - when-needed meetings for problem solving, raising concerns and adjusting the plan.
Debrief - after action meetings to set up for the next brief, and highlight areas for improvement.
Describe five features of good feedback. (5)
Directed towards improvement
Describe the two challenge rule. (3)
This is a thing to do if you have been ignored when raising a concern. Challenge a second time, seek confirmation they acknowledge your concerns. If you’re still not happy, seek out a superior.
Describe the communication tool used for effective phone hangovers. (4)
Situation - what is going on with the patient, who and where they are.
Background - patients clinical background and context of the call
Assessment - what I think the problem is
Recommendation - what I need to do next, and what I need from you.
Describe the communication tool used for effective and detailed hangovers. (10)
I PASS the BATON
Introduction - your job, role
Patient - name age sex location
Assessment - chief complaint vitals diagnosis
Situation - current concerns or changes
Safety concerns - labs allergies fall risk
Background - FHx PMHx medications
Actions - taken and needed
Timings - urgency
Ownership - who is responsible
Next - set up a plan and a backup.
Describe the four types of human error. (4)
Slips - failure of attention
Lapses - failure of memory
Mistakes - rule or knowledge based
Describe a systems analysis. (4)
Also known as a root cause analysis.
A structures and retrospective approach in healthcare to holistically focus on the underlying and contributing factors to a failure.
Name three techniques that could be used in a systems analysis. (3)
Describe a fishbone diagram (4)
Head of the fish is the problem.
Ribs are contributing factors: patient, task, communication, team, education, organisational, individual.
Describe how to set up the Plan-Do-Study-Act system. (3)
Begin with a problem statement - a vague statement that does not in any way place blame or suggest a solution.
Follow up with investigations and a current state analysis, and set SMART goals for improvement.
What is 3636? (1)
The number in UHL that you call to report a patient safety incident.
List five reasons why it can be hard to speak up (5)
Loss of situational awareness
Too much deference to others
Fear of future hostility
Not certain it will make a difference
Describe two systems in place to encourage people to speak up. (5)
Freedom to speak up guardians
Statutory duty of Candour:
- a face to face discussion and bout what happened and why
- a discussion about further actions needed
- a written report on what happened
- an apology.
Explain the difference between first and second order problem solving. (2)
1st order - immediate solving of the problem with no long term effect.
2nd order - the initially longer in time, but long term fix implemented immediately.