Describe: Root Cause Analysis
- Allows you to ask what, how and why
What are the 2 types of root cause analysis?
- 5 why’s method
2. Fishbone analysis
What is the pneumonic used in healthcare associated infections?
SIGHT
Suspect a case Isolate patient Gloves and apron Hand hygiene Test for toxin
What is ‘Gap Analysis’ in patient safety improvements?
Where are we now?
Where would we like to be?
What are the SMART aims in relation to patient safety improvements?
Specific Measurable Attainable Realistic/Relevant Time limited
What is the PDSA cycle?
Plan a change
Do it in a small test
Study its effects
Act on what’s learnt
What are the key legal issues in consent?
- Consent can be written, verbal or non-verbal
- The signing of a form does not make consent valid
- In general no-one can give consent for another adult
What is delegated consent?
- Consent taken for a procedure by someone not competent to carry out the procedure
- NHS Litigation Authority sees this as a big patient safety issue
What is the Independent Mental Capacity Advocacy?
Services to assist decision making for vulnerable unsupported adults in relation to serious medical treatment or placement in long-term care
What are the 5 principles of the Independent Mental Capacity Advocacy?
- Presumption of capacity
- Supported participation in decision-making
- A right to make unwise or eccentric decisions
- Best Interest
- Least restrictive alternative
Define: incapacity
A person may lack capacity if he/she suffers from an impairment or disturbance of mind or brain. This may be temporary or permanent.
The person fails to:
♣Absorb basic information about the pros and cons of an issue or decision
♣Retain the information for long enough to process it
♣Use or weigh up the information
♣Communicate the decision by any means
What is stage 1 of assessing capacity?
- Is there an impairment of, or disturbance in, the functioning of the person’s mind or brain
- It doesn’t matter if this permanent or temporary
What is stage 2 of assessing capacity?
If after being given all appropriate help the person is unable to function to 1 or more of the domains:
- Understand info given to them
- Retain in long enough to make a decision
- Weigh the information in balance
- Communicate the decision
What is a Lasting Power of Attorney?
- A person nomination (at a time when the person had capacity) to act on behalf of the donor when lacking capacity
- They must be registered with the new Public Guardian
- Includes decisions about fnance, health and welfare
- Does not include decisions about withholding life-saving treatments unless specifically stated
- If a doctor has concerns about them, they can be referred to the Court of Protection
What are Court-appointed Deputies?
- The Court of Protection can appoint deputies to make decisions on welfare, health and finance
However, they may not:
- Override a Lasting Power of Attorney
- Refuse life-sustaining treatments
What are Independent Mental Capacity Advocates?
If a person:
• Lacks capacity
• Has no close relative or friend (different in adult protection cases)*
• Has no LPA
• Does not have a court deputy
• Needs to make decisions about serious medical treatment (but not in an emergency situation) or long-term place of care
Then an IMCA should be appointed
It is provided by local authority and are available to healthcare workers by referral
Represent and support the individual and ensure that the principles of the act are followed
What kind is events are unreported?
- Errors considered insignificant
- Near misses = good catches
- Unnoticed errors
Define: crude mortality rate
The number of deaths that occurred divided by the number of admissions to a healthcare provider in a specified time interval
What is HSMR?
- Hospital standardised mortality ratio
- Calculation used to monitor death rates in a trust
- Based on subset of diagnoses that give rise to 80% of in-hospital deaths
What is Dr Foster?
It uses the coded data to predict the expected number of deaths for the case mix seen and compare it to the actual number of deaths
This gives the standardised mortality ratio
What is taken into account to adjust for the case mix?
Age sex deprivation (estimated from post code) Ethnicity Diagnosis Method of admission Previous admission Month of admission Provision of palliative care Comorbidities (using Charlson index)
What can variations in HSMR be because of?
- Variation in standard of care
- Variation in coding
- Variation in community provision
What is SHMI?
Summary Hospital-level mortality indicator
How is SHMI different from HSMR?
It is derived from all admissions to a secondary care organisation, rather than a subset
It is based against the previous 3 year’s national data (compared to the current year for HSMR)
Includes all deaths at 30 days (not just those in hospital)
