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First slideshow

  • Mini Audit is useful for the portfolio
  • Audit = quality control, following clinical practice guideline


  • A continuous process of reviewing healthcare quality
  • Against accepted / EB standards
  • And implementing changes to meet the standard(s) as necessary
  • Repeated to maintain high standards
  • = a positive feedback loop
  • Critical evaluation - why people don't do particular things (ask them why a certain thing isn't relevant to them)
    • People modify guidelines to fit their practice
    • Find out guidelines and who created them, how they work etc, how often people on the ward are taught about them
  • Audit doesn't need ethics approval because it's part of normal practice
  • Notes: ask for 10 successive patient notes from discharge from the hospital
  • Ethics - you need to tell the people that you are watching them and what for
  • Big Brother effect - people behave differently when they're being watched
    • Audits are known to improve quality of care because we know audits improve behaviour
  • "Is that what you'd normally do if you're busy? Or are there particularly parts of the guideline that are harder to do when you're busy?"

Clinical practice guidelines

  • Evidence-based
  • Created by royal colleges
  • Reviewed and updated
  • Introduced to staff and supported in practice
  • You are likely to see some real problems as to why guidelines aren't fully adhered to:
    • What are the underlying cases?
    • How can this be improved on?
  • If guidelines aren't followed, things can go wrong.
  • Hand hygiene is the easy one.
  • 'The killer bs' are why guidelines aren't followed
    • Barriers = lack of time, energy, patients aren't coherent or awake etc
  • Audit
    • Presentation to each other, upload it into eMed for portfolio, tutor marks it

Second slideshow: Medical errors

  • Near miss: you start doing something wrong then realise you were doing it wrong and correct it (almost went bad) - detect as a gauge for when something bad could go wrong
  • Nonpreventable adverse events: side effects of medications (can tell people about it though)
  • Vast minority of adverse events are negligence
  • Consider what good quality healthcare is for:
    • Patients - communication
    • Politicians - optimisation
    • Training doctors - no errors
    • Consultants - effective
  • In Australia, up to 16% of hospital patients suffered an adverse event1
    • 50,000 patients/year suffer permanent disability
    • 18,000 patients/year die
  • Iatrogenic injuries:
    • 35% resulted from a failure of professionalism (not checking tests, being conscientious)
    • Lack of care or attention, failure to request a test
    • Acting on insufficient information, lapses etc
    • 1% due to lack of knowledge
  • Causes of iatrogenic:
    • Drug, Dose, Time, Route
  • 1999 - To err is human: building a safer health system:
    • 44,000 to 98,000 people die in US hospitals each year due to medical error 2
    • Medication errors (USA) result in 7,000+ deaths alone each year

$$ cost

  • The financial cost is huge:
  • USA $37.6 billion each year2
  • In Australia the total health care budget was>$50 billion (2004) and adverse events cost us $2 billion = 4% of the health budget value!*

==Girl's death triggers NSW health inquiry==

  • SMH Thursday, 24 January, 2008
  • “The NSW government has been forced to call an independent inquiry into the state's public health system after a scathing assessment from a coroner investigating the death of a Sydney teenager.
  • Vanessa Anderson, 16, died two days after being admitted to Royal North Shore Hospital (RNSH) with a skull fracture.
  • She had been hit in the head with a golf ball during a morning tournament at Asquith in Sydney in November 2005.“

Warren Anderson

  • There's a big inquiry into this

5 moments for hand washing

  1. When you enter the room
  2. Before you touch a patient
  3. After you touch a patient
  4. When you do a procedure
  5. When you leave the room
  • Best handwashers
    • Nurses and midwives
  • Worst handwashers
    • Doctors and medical students
  • Look at the creepy diagram for changing peoples' behaviour
  • Safety culture = the next diagram. Trouble if one individual is trying to make the workplace safe
    • Useful for audit
  • Increased risk for professional misconduct:
    • Male students
    • Lower SES
    • Failure of early pre-clinical examinations: affects conscientiousness. Less likely to be able to handle a stressful career
  • In doctors:
    • Males, surgeons and GPs had higher rates of complaints
      • Males - don't talk as much, more paternalistic
      • Surgeons - less communication time with patient is more chance of being sued; have a large ego
      • GPs - time poor; have many different kinds of problems with no preparation; different types of patients with different types of needs
  • Trend are present between medical student behaviour and medical practice


  • Low predictive value
  • Significant costs and resources dedicated already
  • Most unprofessional doctors behaved well as students
  • Most students with behavioural problems at university will go on to be good doctors

Professionalism in medical students

  • Significant amount of discourse on policies, codes and opinion pieces
  • Research data on professional behaviour in medical students was lacking
  • What aspects of professionalism should be taught and assed?

What is professionalism?

  • Professionalism is comprised of a set of values and behaviours that underpin the social contract between the public, medical profession and doctors
    • Live up to unwritten rules based on doctors' status in society
  • Major components of professionalism include empathy, honesty, patience, team-mindedness and intellectual curiosity
    • Impatience would mean higher rate of errors because you're hurried
    • Intellectual curiosity: look up something/check it up if you don't know something

Definition of Professionalism

  1. Subordinate own interests to interests of patients
  2. Demonstrates high ethical and moral standards
  3. Behaves according to an accepted social contract
  4. Demonstrates humanistic values such as integrity and honesty
  5. Shows responsibility and accountability
  6. Has a commitment to improve
  7. Copes with complexity and uncertainty
  8. Demonstrates reflective practice
  • Blaming one person does nothing - just causes someone to lose lots of money

Doctors can’t be the only problem ...So what is wrong with the system?

  • Health system prevents honesty and disclosure causing a vicious cycle of repeated errors
  • Blame and shame culture
  • Human error
  • Individual at fault
  • Major inquiries fail to deliver satisfaction to victims or change systems or prevent further errors

Errors are common

  • On the wards, in Specialist Clinics, in General Practice, in the community..
  • Discuss with 2 neighbours:
  • What have you seen or heard? (No names or identifiers)

Examples of common types of errors

  • Diagnostic
    • Error in delay of diagnosis
    • Wrong or outmoded test etc
  • Treatment
    • Error in operation or procedure
    • Error in dose of drug etc
  • Preventative
    • Failure to provide a prophylactic treatment
  • Other
    • Failure in communication

Why do errors occur?

  • Human mistakes
  • System failures
  • Active failures =“unsafe acts” (human)
  • Latent conditions = “resident pathogens” (within the system)

Some examples

  • Active failure:
    • e.g. inaccurate measurement of a dose of a drug
    • e.g.ordering the incorrect test
    • e.g.amputating the wrong limb (it still happens!)
  • Latent condition:
    • e.g.Similar labels on different drugs
    • e.g.inadequate policy on how to deal with patients with same name

Reason’s Swiss Cheese Model

  • Eventually all the holes line up and something goes wrong

Holey cheese

  • Cheese slices = defensive layers within the system, e.g. protecting against:
    • unsafe acts
    • management deficiencies
    • psychological precursors to slips/mistakes.
  • Holes = problems in the system: the active failures and latent conditions.