Flashcards in Session 1 Deck (10):
Describe evidence demonstrating problems of quality and safety
Sub standard care
Variations in health care
Describe theories about why patient safety problems occur
Swiss cheese model:
Hazards --> losses
Holes = active failures + latent conditions
Cheese = layers of defences, barriers, safeguards
Define the term 'active failure'
Acts that lead directly to the patient being harmed
Define the term 'latent condition'
Predisposing conditions e.g. poor training
Define the term 'adverse event'
An injury that is caused by medical management
Can be unavoidable or preventable
Define the term 'never event'
An event that should not happen under any circumstances
Briefly describe policies and organisations for encouraging quality in the NHS
Needs to be effective, safe, quality
Health and social care act 2012
NNS outcomes framework --> NICE quality standards
Quality and outcomes framework (QOF)
Registration and inspection
Define the term 'clinical governance'
NHS organisations are accountable for continuously improving the quality of services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish
Define the term 'clinical audit'
A quality improvement process that seeks to improve patient care and outcomes through systemic review of care against criteria and the implementation of change