Patient Safety in Healthcare

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Questions and Answers

What is defined as the avoidance, prevention, and amelioration of adverse outcomes in healthcare?

Clinical governance

Patient safety (correct)

Patient care

Quality assurance

What is the most common cause of claims in healthcare according to recent statistics?

Surgical errors

Infection control incidents

Medication errors

Slips and trips (correct)

What percentage of patients may experience adverse events following hospital discharge?

20% (correct)

15%

10%

Which of the following is considered an active failure in healthcare?

Human error in administering medication Signup and view all the answers

What does the term 'error' NOT refer to in the context of healthcare?

A deliberate choice by a practitioner Signup and view all the answers

Which area remains the source of the largest claims in healthcare?

Surgery Signup and view all the answers

What is a common consequence of adverse events in healthcare?

Financial burden and pain Signup and view all the answers

What factor is NOT typically associated with the occurrence of errors in healthcare?

Routine practices Signup and view all the answers

What percentage of medication errors occur during transitions in care between primary and secondary care?

76% Signup and view all the answers

Which Act outlines the duties on all at work to protect those affected by work?

Health and Safety at Work etc Act 1974 Signup and view all the answers

What is one of the main consequences of failing to adhere to patient safety principles?

Duties imposed under common law Signup and view all the answers

How many fatalities are reported annually as a consequence of workplace incidents?

235 Signup and view all the answers

What key element should healthcare professionals recognize in their duty to patients?

Rights and obligations Signup and view all the answers

What is the general duty of employers under Section 2(1) regarding health and safety?

To ensure, so far as is reasonably practicable, the health, safety, and welfare at work of employees Signup and view all the answers

What does the Manual Handling Operations Regulations 1992 define as 'manual handling'?

Any transport or support of a load by hand or bodily force Signup and view all the answers

Under the Health & Safety at Work etc Act 1974, what is the consequence of failing to comply with health and safety regulations?

It constitutes a criminal act Signup and view all the answers

What obligation do employees have while at work according to Section 7?

To take reasonable care of their own and others' health and safety Signup and view all the answers

What is a no-lift policy as implemented by health boards?

A protocol aimed to reduce injury by avoiding hazardous manual handling Signup and view all the answers

What type of error occurs when key steps in a clinical task are omitted?

Errors of omission Signup and view all the answers

Which of the following is classified as a lapse in patient care?

Failing to prescribe aspirin after a myocardial infarction Signup and view all the answers

Which of the following best describes a mistake in patient care?

Applying the wrong rule to a patient’s diagnosis Signup and view all the answers

What are latent failures in the context of patient care?

Potential errors not yet identified in policies and guidelines Signup and view all the answers

What impact does communication failure have on patient safety?

It can contribute to misunderstandings that lead to safety claims. Signup and view all the answers

In terms of new technology, what is a major concern with telemedicine consultations?

They lack visual and nonverbal cues for assessment. Signup and view all the answers

What is described as a violation within patient care processes?

Deliberately choosing not to follow established protocols Signup and view all the answers

What is one of the key safety areas targeted by the World Health Organisation?

Errors during transitions of care Signup and view all the answers

What must assessment prioritize when evaluating an individual within a care-planning process?

User-focused and user-led needs Signup and view all the answers

Which of the following describes the requirements of the Control of Substances Hazardous to Health (COSHH) Regulations?

Control employee exposure to hazardous substances Signup and view all the answers

What was the outcome of the case involving Alison Dugmore regarding exposure to hazardous substances?

Damages of £345,000 were awarded Signup and view all the answers

What contributed to the tragedy involving a junior member of staff at the University Hospital?

Working alone without clear procedures Signup and view all the answers

According to the COSHH regulations, what must be done if exposure to hazardous substances cannot be prevented?

Exposure should be adequately controlled Signup and view all the answers

Which type of injury led to the Health and Safety Executive prosecuting South West London Primary and St Georges Mental Health NHS Trust?

Fatal injuries from a psychiatric patient Signup and view all the answers

What personal health issues did Alison Dugmore face due to her exposure to latex?

Asthma, skin problems, and anaphylactic attacks Signup and view all the answers

How much was South West London Primary and St Georges Mental Health NHS Trust fined following the nurse’s death?

£28,000 Signup and view all the answers

Study Notes

Patient Safety Overview

Fundamental principle: "First do no harm" emphasizes patient safety in healthcare practice.
Patient safety encompasses avoiding, preventing, and mitigating adverse outcomes from healthcare processes.

Current Landscape of Patient Safety

NHS compensation bill reached £2.35 billion last year, indicating financial stakes in patient safety.
Most frequent claims arise from slips and trips, followed by medication errors, which account for 11% of claims.
Surgery and obstetrics remain primary sources of significant claims.

Errors in Healthcare

Adverse event rate in health services is approximately 10%.
About 20% of patients may experience adverse events post-hospital discharge, highlighting the need for collaboration between primary and secondary care.

Consequences of Adverse Events

Adverse events lead to pain, disability, psychological harm, and in severe cases, death.
These events impose financial burdens on healthcare systems and personal costs on practitioners.

Types of Errors

Errors can be categorized as:
- Causes: Those responsible for patient harm.
- Events/Actions: The specific actions leading to harm.
- Outcomes: The resultant harm or complications.

Active and Latent Failures

Active failures stem from human errors and equipment failures.
- Include errors of commission (wrong actions taken) and omission (failure to act).
Latent failures represent system flaws that predispose to errors, often unnoticed until an active failure occurs.

Human Factors Contributing to Errors

Common human error types:
- Slips: Mistakes in routine tasks, e.g., miscommunication of patient allergies.
- Lapses: Failure to adhere to protocols, e.g., not prescribing critical medications.
- Mistakes: Errors in judgment due to inadequate knowledge or applying the wrong guidelines.
- Violations: Deliberately ignoring established rules.

Communication Failures

Communication issues contribute to about 90% of compensation claims.
Patients' unique cultural contexts impact their understanding and perspective of healthcare.

Technology and Consultation

While face-to-face consultations prevail, growing use of telecommunication changes dynamics and may lead to errors due to lack of non-verbal cues.
The World Health Organization highlights transitions in care as critical risk areas, particularly with frequent medication errors during these transitions.

Practical Strategies for Safety

Emphasize patient safety as a research and practice priority.
Adhere to local guidelines and seek assistance when uncertainty arises.
Foster risk management and incident reporting procedures within healthcare settings.

Legal Framework for Patient Safety

Statutory duties under the Health and Safety at Work Act 1974.
Common law obligations encompass duty of care, implicating healthcare providers in negligence cases.

Rights and Obligations in Patient Safety

Rights pertain to legally protected interests, while duties ensure respect and protection of those rights in healthcare.

Legal Compliance and Responsibilities

Employers must comply with numerous regulations related to health and safety, including the Management of Health & Safety at Work Regulations and the Control of Substances Hazardous to Health Regulations.

Specific Case Studies

Notable incidents illustrate the consequences of safety breaches, such as a 93-year-old woman who died following misplacement by an ambulance service, leading to fines for negligence.

Manual Handling Protocols

Regulations mandate risk assessment and the implementation of no-lift policies to prevent injury during manual patient handling.
Individualized assessments must focus on patient and worker capabilities.

Control of Hazardous Substances

Employers are mandated to control exposure to harmful substances and ensure health risks are adequately addressed.
Case laws highlight employer liabilities for injuries resulting from hazardous substances, as seen with a nurse’s allergy to latex leading to significant damages.

Consequences of Inadequate Safety Measures

Severe breaches in safety can result in criminal charges and significant financial penalties for the healthcare organizations involved.

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Description

Explore the essential principles of patient safety in healthcare settings. This quiz emphasizes the importance of avoiding harm while providing care, highlighting the challenges posed by modern treatments and infections. Test your knowledge on strategies to enhance patient safety practices.