Making Services Safer

Dr J. Secker-WalkerBSc MBBS FRCA

Emeritus Consultant

University College London Hospitals

Strategic Objectives of Clinical Risk Management

Reduce injuries to patients and staff Identify organisational, system and

environmental problems which may promote human error

Establish early position on liability Learn from accidents by systematic analysis

FREQUENCY OF ADVERSE INCIDENTS

California 1974 - i/p ® 4.6 % New York State 1989- i/p ® 3.5 % USA 1989- surg + icu (p) 45 % Australia 1994- i/p ® 16

% England (pilot) -i/p ® 10%

ANALYSIS OF SURGICAL ADVERSE EVENTS

37.5% Individual error - poor judgement or poor technical performance

15.6% Interactive communication problems between teams or

individuals 9.8% Administrative decisions - staffing

levels, inadequate equipment, etc...

CAUSES OF ACCIDENTS

75% Human error 15% Equipment failure 10-30% Human - Equipment

interface

CAUSES OF ACCIDENTS

Usually multi-factorial; very seldom simple Active Human Failures = Unsafe acts by

individuals at the sharp end Latent Human Failures = Inappropriate

organisational policies or decisions - or lack of them

Concept of Resident organisational or environmental “Pathogens” waiting their time

The Development of an Incident

Corporate Culture

Local climate SituationTask

Defence Barriers

Management decisions and organisational processes

Error-producing conditions

Violation-producingconditions

Errors

Violations AccidentsIncidents

Latent failures in defences

J. Reason 1994

ACTIVE HUMAN FAILURES

UNINTENDED ACTION;

Attention failure, memory lapse, interruption INTENDED ACTION; Rule based mistakes Knowledge based mistakes Violations - breaking rules

Human Factors – Attitudes Associated with Critical Incidents

Anti-authority …don’t tell me what to do Impulsivity…..do something quickly Invulnerability….it won’t happen to me Macho….I’ll show you I can do it Resignation…what’s the use, it’s up to the

surgeon

ERRORS

It is the circumstances of their occurrence that determine outcome

Errors that are inconsequential in one situation can be catastrophic in another

Kettle and toaster switches Freezer switch Kegworth - engine switches

ERROR PRODUCING CONDITIONS

High workload Inadequate knowledge, ability, experience Poor interface design Inadequate supervision / instruction Stressful environment Mental state; fatigue, boredom Change

Violations – Breaking Rules or not following Policy

Routine - 79mph on motorway Occupational - required just to do the job Exceptional - breaking the rule saves the day Optimising - bored or something? Sabotage

DEFENCES

Clinical staff - the human condition Pathways of care Preoperative check-lists / swab counts Up-to-date Policies Training in new procedures/equipment Monitoring in anaesthesia and ICU EQA in histopathology Post-take ward rounds

The Human Condition

Error prone slips lapses mistakes violations

Acting as a defence adjustments compensations recoveries improvisations

Teamwork

Stable teams improve the quality of care Team members act as a ‘defence’ for colleagues Inadequate staffing, medical shift systems and

patients on outlying wards make maintenance of consistent teams very difficult to achieve

Pathways of care provide a clear, timed route-map for each patient’s care needs and reduce the risk of communication failures leading to adverse patient incidents

Contributions from Senior Doctors

Junior staff teaching Equipment training for junior staff Appropriate staffing levels Clearly set responsibilities – when to call Emergency room safety procedures: discharge

of children, x-ray review times Mechanism for decisions on delegation

(is X ready to do a hernia unsupervised?)

Organisational Approaches to Accidents

Person (pathological) approach. Focuses on errors and violations of the individual. Remedial effort directed at people at the sharp end

Bureaucratic approach – safety ‘by the book’ with local fixes not global reforms

System (generative, high-reliability) approach. Traces causation to the system as a whole. Remedial effort directed at the environment and organisation. Individuals encouraged to bring concerns to higher management

James Reason 2005

System Approach

Who knows best where the system fails? Staff at the coal-face How do you get them to tell you? Make Incident Reporting constructive and

free of the fear of blame

Disciplinary PolicyA “JUST” POLICY

Should motivate all staff to report Incidents Staff should be free of the fear of disciplinary

action if they report or own up to errors, mistakes or some violations

Exceptions: Criminal behaviour; malicious reporting, gross misconduct, serious breaking of known rules, repeated errors, covering up.

NPSA Incident Definition

“ A patient safety incident is any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS funded healthcare.”

This is also referred to as an adverse event/incident or clinical error, and includes near misses.

HSC Toronto Incident Definition

An Incident is any Occurrence which is not consistent with the routine care of the Patient or the routine operation of the Institution

A near-miss is an Occurrence which but for luck or skilful management would in all probability have become an Incident

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Women & Children Surgical Medicine Linear (Medicine) Linear (Women & Children) Linear (Surgical)

Obstetric Incident Activity

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Staff Shortages / Unit Closure Unavailability of appropriate staff Total all other A&B Total incidents

Total Patient Care Incidents for between October 2000 and September 2003

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Month & Year

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Patient Care Incidents for August & September 2002 to 2004

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Aug 2002 Aug 2003 Aug 2004 Sep 2002 Sep 2003 Sep 2004

Month & Year

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*A Sentinel

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B Serious

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Swab and Instrument Count Oct 2000 - Sep 2003

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Surgical foreign body left in situ Sw ab/instrument count discrepancy

INQUIRY 1

INVESTIGATION29

WALL PAPER

300

WHEN DO YOU HOLD AN INQUIRY?Heinrich ratio

Example : Patient death from medication misadministration / wrong limb / poor performance - incident analysis

Example : Significant medication error, but patient survives

Example : Missed dosage causes no harm. Majority of medication errors / staffing problems - risk trend analysis

The Incident Decision Tree

NPSA procedure to assist managers determine a fair and consistent course of action towards staff involved in a patient incident.

The Deliberate Harm Test – harm intended The Incapacity Test – ill or substance abuse The Foresight Test – adhered to protocols? The Substitution Test – likely peer performance

The sad tale of Mr B aged 18

Sunday 11/11: at gym, hits head on bar Tuesday 13/11: left eye puffs up Wednesday 14/11: off college, eye nearly closed Thursday 15/11: eye completely closed – to GP -

given eye ointment. Sunday 18/11: less eye swelling, reduced appetite,

some vomiting, disliked sister’s music Friday 23/11: to (different) GP – put on antibiotics

and recommended to go to hospital ER

The sad tale of Mr B aged 18

Friday 23/11: seen in ER. Fit shortly after arrival. Pyrexia 37.7. Skull x-ray. Blood count + chem path. Report same day: wbc and neutrophils raised.

Saturday 24/11: seen by neurosurgical registrar: “no fever”. GCS 15/15. Skull x-ray reported as NAD by radiologist. No mention in the notes of the raised wbc. For brain scan

Saturday 24/11: brain scan read by neurosurgical registrar. “no intracranial haematoma, no skull # noted”

The sad tale of Mr B aged 18

Sunday 25/11: scan and patient reviewed by consultant neurosurgeon. Not made aware by (different) registrar that accident had occurred 14 days previously. No mention of wbc or pyrexia on admission. Asked about rhinorrhœa – none, discharged home –”no further seizures, for home today. Not for follow-up”.

The sad tale of Mr B aged 18

Monday 26/11: Neuroradiologist reports on CT scan. Suspicious of orbital #. Suggests urgent discussion with neurosurgeon. Report sent to ward where patient had been.

Tuesday 27/11: mother rings (3rd) GP to say son is still not himself. GP says that he will be ok because hospital had just discharged him! No communication had been received from the hospital.

The sad tale of Mr B aged 18

Friday 30/11: patient found dead in bed by mother. Not able to resuscitate

Friday 30/11: Surgeon sees CT report and wbc result for the first time. Discharge letter to GP not filled in and still in the back of the notes.

Saturday 1/12: Post-mortem shows a brain empyema. Coroner’s inquest found cause of death to be accidental.

NPSA Root Cause Analysis

What happened Why did it happen? What were the most proximate factors -

human, equipment, controllable/ uncontrollable environment?

Why did that happen -what systems and processes underlie those proximate factors - human resources, information management?

Framework for an action plan

Unpicking an Incident

PROBLEM

COMMUNICATIONORGANISATIONAL

FACTORSTASK FACTORS INDIVIDUALS PATIENTS

WORKING CONDITIONS

EDUCATION &TRAINING

DEFENCES

The sad tale of Mr B aged 18

Please check the Intranet to ensure you have the latest version

Junior surgeon reporting scan

Organisation &

Strategic

Tasks

Patient

Consultant not aware of scan result or patient history. GP also unaware

Individual Staff

Communication

Working Conditions

Education &

Training

No procedure for documenting and acting on concerns, or about notes of discharged patients

Radiologist did not ring surgeon. Ward manager did not ensure CT scan result shown to consultant No note about wbc or pyrexia

Problem of ER results never resolved

Results not filed in notes . ? any useful handover 3 different GPs

Weekend shift working – EU WTD problem. Neuroradiologists not on at weekends

Little or no training about dangers of poor communication and shift working

Apparently ok, observations became minimal

CACA ET DECLINOS MEDICOS

INSCRIPTION ON A TOMB IN OSTIA ANTIQUA

Circa AD 57

Relentless Striving For Targets –a cautionary tale

HMS Camperdown – mid 19thC Transition from sail to steam Surplus sailors Competitive culture of ‘brightwork’ – shiniest

surfaces and glossiest paintwork Watertight doors…………..

Reflections

Key points of interest for you How does it compare to local situation Identify areas for action in your own setting