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Patient Safety

• Understanding Human Error in Healthcare

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Aims

• To develop the knowledge, skills and attitudes
  that promote
• the reduction of medical error to improve patient
  safety
• learning from error in healthcare to improve
  patient safety

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Learning Outcomes

• Knowledge
• What is a medical error?
• How and when does this happen?
• How do people make errors?
• Why do people make errors?
• What happens when an error is made?
• How do people feel when they make errors?

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Learning Outcomes

• Skills
• Recognition of error
• Dealing with error
• Reporting and learning from error
• Supporting others involved in error

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Learning Outcomes

• Attitudes
• Focuses on cause rather than culprit
• Willing to learn from mistakes
• Being prepared to acknowledge and deal with error
• Being prepared to reflect on practice
• Trust and respect

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Introduction and Background

• Human Error- We cannot change the human
  condition, but we can change the conditions under
  which humans work.
• (James Reason BMJ March 2000)

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Personal vs System Approach

• Personal approach
• focuses on the unsafe acts
• sharp end- name and shame
• System approach
• errors seen as consequence not cause
• aim to build defences and safeguards
• Health care now learning from other industries
• High technology systems have many defensive
  layers - like a Swiss cheese
• Active failures
• Latent conditions Reason BMJ March 2000

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DANGER
Some 'holes'
due to active
failures
Defences
in depth
Other 'holes'
due to latent
conditions
From Reason 1997
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Definitions

• Adverse patient incident - any event or
  circumstance arising during NHS care that could
  have or did lead to unintended or unexpected
  harm, loss or damage.
• Harm - injury (physical or psychological),
  disease, suffering, disability or death.
• Incidents that lead to harm- Adverse Events.
• Incidents that do not lead to harm - Near Misses.
• Other terms which may be used - clinical
  incident, critical incident, serious untoward
  event, significant event
• (National Patient Safety Agency 2001)

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What is happening? the world

• Australia Australian Patient Safety Foundation
  established as an association 1989
• USA National Patient Safety Foundation
  established 1998
• Canada Canadian Patient Safety Institute
  established 2003
• WHO World Alliance for Patient Safety launched
  2004

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What is happening? - UK

• High profile reports of errors leading to patient
  morbidity and mortality e.g. Bristol
• 2000 - Department of Health publish - An
  Organisation with a Memory
• 2001 - National Patient Safety Agency established
  in England
• to improve safety of patients by promoting a
  culture of reporting and learning from patient
  safety incidents

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National Patient Safety Agency

• The National Reporting and Learning System on
  patient safety incidents
• Aims
• To identify trends and patterns and underlying
  causes
• To develop models of good practice at national
  level
• To improve working practice by feedback and
  learning
• To encourage education and training (NPSA
  Seven steps to patient safety, Nov 2003)

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Discussion

• If people try hard enough they will not make any
  errors
• If we punish people when they make errors, they
  will make fewer of them

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Extent and Nature of Adverse Events in Healthcare

• 850,000 adverse events per year (NHS)
• 44,000 incidents fatal
• Half are preventable
• Accounts for 10 of admissions
• Costs the service an estimated 2 billion per
  year (additional hospital stays alone, not taking
  into account human or wider economic costs e.g.
  litigation)

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Factors Contributing to Human Error

• Environmental Factors
• Light
• Noise and Vibration- Alarms!
• Temperature
• Humidity
• Restrictive/ protective clothing
• Equipment layout and design
• Physical environment

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Factors Contributing to Human Error

• Some examples of personal factors
• Fatigue
• Stress
• Workload
• Distraction
• Drugs/ Alcohol
• Hypoglycaemia
• Hypovolaemia

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Professional Cultural Issues Underlying Error

• A definition of culture
• how we do things around here

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Reporting Systems

• Some National Examples
• Scottish Audit of Surgical Mortality
• National Confidential Enquiry into Patient
  Outcome and Death
• Why Mothers Die Report on Confidential Enquires
  into Maternal Deaths in the UK
• The Confidential Enquiry into Stillbirths and
  Deaths in Infancy
• Yellow Card - BNF
• Royal College of Anaesthetists - Critical
  Incident Reporting
• Scottish Confidential Audit of Severe Maternal
  Morbidity
• Some Local examples
• OR1 forms / Medication Error reporting forms
• Significant Event Analysis in General Practice
• Risk management and MM meetings
• Paediatric Surgical error Book

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Factors Contributing to Successful Error Reporting

• Culture - just, reporting, flexible, learning
• Treats less experienced staff as professionals
• Accept human fallibility even good doctors!
• Training on safety issues
• Annual appraisal
• Ground rules established - acceptable and
  unacceptable behaviour

• Support / trust / leadership
• Well run - good input and change implemented with
  good communication
• Consistency
• Clear instructions
• Anonymity
• Confidential
• Voluntary

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Barriers to Successful Reporting

• Fear of individual / organisational repercussion
• Defining reportable errors too narrowly
• Length of contract / time in job
• Workload involved - usually time (form filling)
• Culture of fear of losing an otherwise good
  nurse / doctor
• Where reporting has not brought about change
• Uncertainty right and wrong - differing opinions

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Disclosure

• What does it feel like?
• What needs to be done?
• Write it all down
• Document in the patients notes
• Tell your consultant
• Local reporting system
• Write to GP?
• Tell the defence union
• COMMUNICATE! Patient and their relatives

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Communication

• Needs to be handled carefully- all parties in
  highly charged emotional state
• Relatives- distressed / anxious / angry
• Health workers- panic / guilt / uncertainty /
  anxiety
• CALM
• Enlist help of colleague
• Statement of situation and apology
• Bad news given - recipients should be offered
  privacy, access to phones, offers to call family
  / friend
• Organise future meeting
• from Confronting errors in patient care
  Firth-Cozens, Redfern Moss

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Meeting with Relatives/ Patients

• Ensure all facts are collected and available
• If patients have special needs- arrange
  interpreters
• Mutually convenient time
• Comfortable environment- no interruptions eg
  staff / phones / bleeps
• Introduce yourself clearly
• Establish who is present and why
• Explain how the meeting will progress
• from Confronting errors in patient care
  Firth-Cozens, Redfern Moss

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Meeting

• Explain facts in clear, jargon - free language
• Identify unresolved issues and ensure these are
  being investigated further
• Patients current condition and probable outcome
  should be described honestly
• Check on understanding
• from Confronting errors in patient care
  Firth-Cozens, Redfern Moss

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Language

• Try not to attribute blame unless clear cause
• Express regret - We are extremely sorry that
  your
• Avoid comments like I can understand how upset
  you must be
• Rather In similar circumstances I think most
  people would feel as you do now, but I can assure
  you that we want to help you to deal with it
• Person apologising on behalf of the organisation
  - impartial(?)
• Be prepared for a variety of emotional reactions
• from Confronting errors in patient care
  Firth-Cozens, Redfern Moss

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Plan

• Outline what treatment plan is now being
  undertaken
• Reassure that all possible measures are being
  taken to resolve harm done
• Explain what is being done to prevent same thing
  happening again
• Arrange further meeting if appropriate
• Offer a break?
• Procedures for compensation
• Emotional support
• Details about full inquiry
• CONCLUSION
• from Confronting errors in patient care
  Firth-Cozens, Redfern Moss

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Support Systems

• Your colleagues!
• Doctors Plus
• See patient safety website for details
• Sick Doctors Trust
• For doctors who are suffering from addiction
• www.sick-doctors-trust.co.uk/
• A Framework of Support
• GMC
• National Counselling Service for Sick Doctors
• The British Doctors and Dentists Group
• BMA Stress Counselling Service