patient safety: why hospitals should fly
DESCRIPTION
Sue Hendy, Director, Women's Children & Youth Services Obstetric & Gynaecology Department, from Westmead Hospital, Western Sydney Local Health District has presented at the Obstetric Malpractice Conference. If you would like more information about the conference, please visit the website: http://bit.ly/10xh1iOTRANSCRIPT
Why Hospitals MUST Fly!
Risk Assessment
Approach to Health Care
Acknowledgements to J Nance
Sue Hendy
1
Objective
Human Factors in healthcare
Clinicians and women
Environment system and culture
Leader versus commander
Inspire you to view world in a different way
2
Deaths in Healthcare due to adverse outcomes likened to
aircraft disasters & 100% mortality
Risk Rating
Activity Deaths/1m people/year
Deaths/100m hrs of exposure
Being pregnant 150 1
Being in traffic (overall in any capacity) 15,000 50
Flying in commercial aircraft 50 100
Being a patient in acute care hospital 33,000 2,000
Safety & Ethics in Healthcare: Getting it Right: Runciman et al 2007
Events %
Problem with or failure of an op or procedure 18%
Hospital acquired infection 16%
Wrong, delayed or missed diagnosis or treatment 14%
Complication of a body system
Hospital acquired injury
Medication error or problem with a drug
11%
8%
7%
5
Anne Walsh-Plaintiff Lawyer :
Quotes from Day 1
• We all do things wrong everyday
• Speak up if something is wrong
4 Pillars
• Clinicians
• Women
• Environment, system and culture
• Leaders ability and style
National Registration
(ANMC) Competency Standards
Clinical Guidelines
Peer & Multidisciplinary review
SAC 1 sentinel event: death, severe disability
Root Cause Analysis
SAC 2 – near miss
8
Question?
10
E
Environment, system and culture:
Minimise human error through training, procedural adherence, checklists, evaluations & standardisation
Build the system to fully expect and be able to safely absorb those errors that will still occur
BUT….
DESPITE all the training, and the buffers there is at least a 50% chance of something going wrong at any time
“Alas, culture is not what we
say, what we think, what we
mean, or even what we intend;
.”
Jon Burroughs, MD
12
Leadership
Oppression Theory
Major characteristics of oppressed behavior
stem from the ability of dominant groups to
identify the “right” norms and values & from their
power to enforce them.
13
15
HIERARCHY
Staff complain to mgror each other
Boss solves problems
People know their place
No feedback sought
Secrecy and blame
Control as key
Different rules for different roles
16
17
We Need a Patient Safety System
Built to Serve the Woman , not just the doctor or staff!
In which doctor is the TRIBAL LEADER, not the COMMANDER.
In which collegial interactive teams are not just a STANDARD, they’re a CORE VALUE!
19
We need a SYSTEM in which…
The absence of collegiality is NOT TOLERATED by anyone at any time for any reason.
The goal of absolute Patient Safety is a CORE
VALUE, not a top-down driven ideal
Every participant takes pride in how they’ve adapted to being an Imperfect Human.
19
20
We Need a SYSTEM in which…
ABUSIVE BEHAVIORS or ABUSIVE ABSENT BEHAVIORS are not tolerated by ANYONE.
Every person enthusiastically accepts
responsibility for every patient & every situation
they encounter
Anyone can take care of your Loved One.20