Things that go bump ''

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• Things that go bump ..
• or
• The mistakes are out there just waiting to happen
• A personal view of patient safety
• B Cowan

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John Gillies

• Edinburgh
• MC
• Reader in Anaesthesia
• Hypotension
• Safety

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With advances in surgery the time factor is to a
certain extent ignored partly because of the
faith that anaesthetists have engendered and
fostered in the less toxic agents and newer
methods now employed.
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With advances in surgery the time factor is to a
certain extent ignored partly because of the
faith that anaesthetists have engendered and
fostered in the less toxic agents and newer
methods now employed. Under the present
abnormal conditions there is growing up a group
of younger surgeons in wholetime hospital service
who, untrammelled by the rush of competitive
surgery develop what might be called an easy
going tempo.
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With advances in surgery the time factor is to a
certain extent ignored partly because of the
faith that anaesthetists have engendered and
fostered in the less toxic agents and newer
methods now employed. Under the present
abnormal conditions there is growing up a group
of younger surgeons in wholetime hospital service
who, untrammelled by the rush of competitive
surgery develop what might be called an easy
going tempo. The same might be said of the
younger generation of anaesthetists who tend to
over-elaborate their part and so extend
unnecessarily the time the patient is under the
anaesthetic.
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What am I ?

• They tell me that the medical director is an
  anaesthetist,
• Retired professor of obstetrics quoted in Evening
  Times April 2004

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What am I ?

• They tell me that the medical director is an
  anaesthetist, well everyone knows that means hes
  an eejit
• Retired professor of obstetrics quoted in Evening
  Times April 2004

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Patient Safety

• To err is human
• Organisation with a memory
• CNORIS
• Safety First
• Scottish Patient Safety Programme

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Incidence
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Incidence

• 44 - 98000 Americans die/year (IOM 1999)
• 4 - 17 of admissions worldwide
• 300K - 1.4M events in England each year
• 35 - 44 of events are preventable
• 7.5 - 10 of events lead to death

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Incidence - Scotland

• Retrospective case note review of 450 records
• Consensus approach
• Overall incidence of adverse events 7.9
• 43 deemed preventable
• 59 increased LOS or led to readmission
• Only 10 identified by hospitals reporting
  system
• Williams et al Scot Med J 2008 53 26-30

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In the beginning ..

• To Err is Human Building a safer Health System
  
• Institute of Medicine 1999
• 44,000-98,000 patients die as a direct result of
  medical incidents every year in the US
• Jumbo jet crashing every day

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To err is human

• Old data
• Previously analysed and published (JAMA)
• Not individuals but systems
• Complex
• Blame not the answer

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To err is human 5 years on

• Successes
• KCl
• Warfarin
• HAI
• AHRQ (2004) no improvement ( used insurance
  claims)
• Very few large controlled studies

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5 years on

• Recognition that the best way to improve quality
  and safety is to change the systems
• Congress 50M for research
• By 2004 all into IT development
• List of effective practices (11 of 30)
• Legislation to enforce stricter reporting
• Working hours reduction in residency programmes
  compulsory

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Organisation with a memory

• Major initiative
• CMO personal endorsement
• Problems Identified
• No mechanism for near miss reporting
• NHS culture does not encourage reporting and
  analysis
• NHS does not learn quickly or consistently from
  the systems available to it

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Organisation with a memory

• Recommendations
• Unified mechanism for reporting and analysis
• A more open culture where things can be reported
  without fear of reprisal
• Mechanism to ensure that where lessons are
  identified the necessary changes are put into
  practice this needs to be actively managed
• A much wider appreciation of the value of the
  system approach in preventing, analysing and
  learning from errors
• Appropriate links between systems for learning
  from failure and those for addressing poor
  performance

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At the moment we are simply too slow to act to
ensure that other patients are not harmed by the
same sources of risk Sir Liam Donaldson
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Safety First

• Failure of NPSA
• Safety moving too slowly
• Safety at one remove from Board agenda

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Safety First

• NPSA to collect and analyse data
• Patient safety function to SHA
• Trust chairs and CEOs identified as responsible
  for safety
• Healthcare Commission role expanded
• NICE to develop technical solutions
• Education in safety
• Greater openness/ develop champions
• National Patient Safety Forum

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How was it for you ?

• NPSA
• Massive incident database - ? use
• 11 do not dos

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In Scotland

• Clinical Negligence and Other Risks Indemnity
  Scheme (CNORIS)
• Fund for indemnity over 35000
• All trusts pay in based on assessed risk
• No claims bonus
• Reduction for performance against Standards

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CNORIS

• Level 1 for all Trusts by 2002
• Level 2 never implemented
• Risk Management absorbed into QIS generic
  standards

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Achievements

• First systematic approach
• Incident reporting and review established
• Clinical risk committees/Risk Registers
• Top Down
• Tick Box
• Usual suspects
• Short lived management focus
• Incident reporting only picks up 5-10 of
  incidents causing harm compared with
  retrospective case note review
• Williams et al Scot Med J 2008 53 26-30
• Sari AB-A et al BMJ 2007 334 79

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Problems

• Rely on self reporting
• Top down
• Never become part of Board agenda
• Ensure learning is universal
• Measurement and results
• Limited or no feedback to staff
• Do not change the culture

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The Evidence

• Working Hours
• RRTs

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Working hours

• 1984 Libby Zion
• New York Hospital
• Fatigued residents
• Reduced hours to less than 80 hours/week
• More complications after the reduction
• Asch et al NEJM 318 1988 771-5
• More handovers
• Do doctors sleep if given time off ?

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Working Hours

• Simulators show impaired performance if tired
• Worse at laparoscopic surgery after a sleepless
  night (Taffinder 1998)
• Task performance worse
• BUT
• Practising good Medicine is more than tasks

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Working Hours

• 2000 average hours in GGHB 83.4/week
• 2008 average hours in GGC 51.7/week
• Cost around 3M/year
• Safer ?
• Handovers
• Shift systems

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Working Hours

• Meta analysis
• Studies from 1966-2004
• Started with 1200 ended up with 7
• Gottlieb (1991) fewer medication errors
• No change in other outcomes
• Medication is a task
• Howard (2004) lower mortality in years after the
  reduction in hours
• But not due to hours as all showed the same
• Complications, test delays may be more sensitive
  to decreased continuity
• No evidence of improvement
• Fletcher et al Ann Intern Med 2004141851-857

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Rapid Response Teams

• Bring competent clinicians to bedside of
  deteriorating patients
• 1 of the 6 interventions used by IHI in Save
  100,000 lives campaign
• University Hospitals Collaborative
• Joint Commission on Accreditation of Healthcare
  Organisations
• Not to do is malpractice

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Rapid Response Teams the Evidence

• 10 studies 8 (5) observational, 2 randomised
• Observational 2 show statistically significant
  improvements in mortality, 2 improve but not ss
• Observational 3 show statistically significant
  falls in cardiac arrests
• Randomised 1(single centre) showed reduction in
  mortality (Priestley 2004)
• Randomised 1 No statistically significant
  benefits (MERIT Study Hillman 2005)

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RRT the evidence

• MERIT study (Hillman et al)
• 125, 132 patients 23 hospitals
• Underpowered ?
• Variation in implementation of protocols
• Control hospitals had up to 50 pre arrest
  calls
• Meta analysis in 2007 concluded that there is
  weak evidence that RRTs lead to a reduction in
  mortality and cardiac arrest rates but further
  large RCTs needed before they become a standard
  of care
• B D Winters et al crit Care Med 2007 35 1238-1243

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A New Beginning.

• Health Foundation
• 4 pilot sites in 2004 including Tayside
• Deming 1950s Japanese model for improvement
• PDSA cycles
• Care processes
• Measure change robustly
• Spread
• Leadership

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Reliability in US Health System

• 439 indicators of clinical quality of care
• 30 acute and chronic conditions
• Medical records for 6712 patients
• Participants had received 54.9 of scientifically
  indicated care (Acute 53.5 Chronic 56.1
  Preventative 54.9)
• The Defect Rate in technical quality of American
  health care is approximately
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• McGlynn, et al The quality of health care
  delivered to adults in the United States. NEJM
  2003 348 2635-2645

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The Sequence for Improvement
Make part of routine operations
Spreading a change to other locations
Test under a variety of conditions
Implementing a change
Testing a change
Theory and Prediction
Developing a change

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Scottish Patient Safety Initiative

• IHI
• Never before in a whole country or a whole state
• Scotland all acute units
• 3-5 years
• Not in the community at present but planned
• Board system makes this unique
• 21 pilot sites with 299 to go

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SPSI

• Based on making healthcare reliable
• Leadership - Walkrounds
• Care Bundles
• Casenote Review
• Medicines management
• Critical Care
• Perioperative
• Ward

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SPSP Timeline
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Leadership

• Outcomes are better in hospitals where
• The Board spends gt25 of its time on quality and
  safety.
• The Board receives a formal quality measurement
  report.
• There is a high level of interaction between the
  board and medical staff on quality strategy.
• Executive Performance Review is based in part on
  quality and safety performance.
• The CE/COO is identified as the person with the
  greatest impact on Quality Improvement

Vaughn T, Koepke M, Kroch E, et al. J of Patient
Safety. 200622-9.
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Outcome Aims

• Mortality 15 reduction
• Adverse Events 30 reduction
• Ventilator Associated Pneumonia 0 or 300 days
  between
• Central Line Bloodstream Infection 0 or 300 days
  between
• Blood Sugars w/in Range (ITU/HDU) 80 or gt w/in
  range
• MRSA Bloodstream Infection 30 reduction
• Crash Calls 30 reduction
• Harm from Anti-coagulation 50 reduction in ADEs
• Surgical Site Infections 50 reduction

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Critical Care
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Perioperative
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Interventions that when implemented together will
achieve significantly better outcomes than when
implemented individually
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Evidence

• 10 units in Wales
• 10656 admissions since 2002
• Hospital Mortality and unit LOS
• 51 months pre/ 19 months post
• National compliance rates over 95
• No significant reduction in mortality or LOS
• K.M.Rowan et al 2008 21st ESICM Annual Congress
  S198 (abstract)

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Evidence

• 1.5 years too early
• Compliance does not equal delivery
• Evidence base for bundles weak ?

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Evidence 2

• ICU in Wales (8 beds, 900 bed trust)
• APACHE Score did not change 17.3/17.4
• Mean LOS from 6 days to 2.7
• VAP from 24.39 per 1000 intubated days to zero
• Requiring tracheostomy to wean decreased from
  22.5 to 12.1
• Pharmaceutical costs fell by 78000 over 2 years
• Throughput increased by a third 343 more in 2
  years
• Less nightmares and hallucinations
• Nurses felt more part of the team
• B Tehan , S OKeefe JICS 2008 224-226

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Conclusion

• Unique situation
• Government to Ward
• Opportunity
• Make a national change
• Produce the research
• 5 years to make this count

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Prescribing

• A 600 bed hospital where each stage of the
  process is 99.9 error free will still experience
  4000 drug errors per year
• Leape L. In Human error in medicine

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Current Reliability

• Good people working hard will not be able to
  overcome the complexities of todays systems of
  care to prevent errors
• Studies show that human beings make errors
• Misreading errors 3 in 1000
• Omission in the absence of reminders 1 in 100
• (BMJ March 18 2005 Tom Nolan)
• NCEPOD report on critical care (May 2005) shows
• 27 of hospitals have no early warning system
• 44 of hospitals have no outreach
• 66 of admissions to ICU were unstable for gt12hrs
  (in hospital gt24hrs)
• 25 were not reviewed by consultant intensivist
  in first 12 hrs
• In ICU frequent deficiencies in care less than
  good in 47
• Deficiencies in care may have contributed to
  death in 11
• (National Confidential Enquiry into Perioperative
  Death)

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HAI

• MRSA
• C Difficile

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Hip Fracture
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Waiting Times
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Cancer Tracking
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VAP results
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Ventilator Bundle

• Elevation of the head of the bed
• Daily sedation vacations
• Peptic ulcer prophylaxis
• DVT prophylaxis
• Tight control of glucose
• Daily assessment of readiness to wean
• Interventions that when implemented together will
  achieve significantly better outcomes that when
  implemented individually
• Evidence ?

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The Improvement Guide, API
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Other Achievements

• Working Hours
• HAI
• SASM
• Hip Fracture
• Waiting times
• Cancer tracking

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Why are doctors not involved

• Culture of medicine
• Complexity system and professions
• Individual Professional Autonomy
• Hierarchical with diffuse accountability
• Lack of Leadership
• Lack of robust measures
• Reimbursement ( may be changing)

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SASM

• First national review of all deaths
• Universal participation
• HDU
• Surgical profile
• Local review
• Appraisal/revalidation

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