Patient Safety in Womens health: View from the National Observatory

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Patient Safety in Womens healthView from the
National Observatory

• Prof James Walker
• Clinical Associate
• National Patient Safety Agency

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Background

• The NPSA
• was established July 2001
• is a Special Health Authority
• has been created to co-ordinate efforts to
  identify and learn from patient safety incidents

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Clinical Governance

• Governance Developed
• An organisation with a memory, which looked at
  learning from adverse incidents in the NHS
• and
• Building A Safer NHS for Patients, which set out
  the governments plans to address OWAMs
  recommendations.

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Why is patient safety important?
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Medicine in the old days was simple, safe and
ineffective. Now it is complex, very
effective but potentially dangerous

• Sir Cyril Chantler,
• Chairman of the King's Fund? Chairman of Board
  GOSH

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Maternal mortality by cause (EW) 1935-78
450
400
Abortion and miscarriage
350
Prolonged labour, trauma and other causes
Toxaemia
300
Haemorrhage
Deaths per 100,000 total births
250
Puerperal sepsis
200
Puerperal phlebitis, thrombosis and embolism
150
100
50
0
1935
1940
1945
1950
1955
1960
1965
1970
1975
Source General Register Office and OPCS,
Reproduced in Birth counts, Table A10.1.3.
Graph by Alison Macfarlane
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Maternal Mortality in Iraq
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Maternal Mortality in Iraq

• Massive Obstetric Haemorrhage 28
• Post Abortion 19
• Eclampsia 17
• Infection 15
• Post Anaesthetic and Other 14
• Obstructed Labour/Ruptured Uterus 7

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Obstetric Claims

• Obstetric claims account for over 70 of all NHS
  litigation expenses with an average cost of
  cerebral palsy cases of 1.5m.
• Current estimate that obstetric claims amount to
  400m of total 600m projected NHS costs.
• Source
• Learning from litigation an analysis of claims
  for clinical negligence
• Vincent, Davy, Esmail, Neale, Elstein, Cozens,
  Walshe
• August 2004

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A problem in maternity services?

• Findings from root cause analyses of 37 adverse
  events/near misses in obstetrics (Ashcroft,
  2002)
• in 92 cases there no guidelines or protocols to
  advice on clinical practice or organisational
  issues
• 49 members of staff were unfamiliar with labour
  ward protocols and failed to follow them
• CEMD report Why mothers die 1997-1999
  highlighted need for guidelines to be used
• women are still dying of potentially treatable
  conditions where the use of simple diagnostic
  guidelines may help

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Fire risk
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"First, Do No Harm"

• Most practitioners are caring individuals
• Highly skilled
• Highly trained
• But we still make mistakes
• Usually in repetitive (normal) tasks
• Omission
• It is not usually the emergency

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Problems for the Beaver

• Learn task but watching and doing
• Trial and Error
• Learning ends with the accident
• No audit trail of problems
• No system memory
• No guideline development
• Continued accidents
• The system is inherently dangerous

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Safety First
Safety First highlights key areas for improvement
in current safety reporting systems in the NHS.
These include

• Simplifying and encouraging reporting of safety
  incidents
• More rapid reporting and notification of serious
  incidents to the NPSA within 36 hours leading to
  more rapid learning
• Capturing risky situations
• Using patient safety data to inform learning and
  action locally analysis, learning and feedback.

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Event Reporting

• Mainstay of risk management
• Part of every-day practice
• Within the airline industry
• routine error (near miss) reporting followed by
  root-cause analysis and risk management, has led
  to a 4 fold reduction in major airline incidents

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Error Analysis

• The traditional way
• person approach
• individual involved is questioned
• the problem tackled at that level
• Tackling the individual
• does not remove the pre-existing risk of error
• the error trap

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Person Approach

• "If a surgeon has made a deep incision in the
  body of a man with a lancet of bronze and saves
  the man's life, or has opened an abscess in the
  eye of a man and has saved his eye, he shall take
  10 shekels of silver.
• If a surgeon has made a deep incision in the body
  of a man with his lancet of bronze and so
  destroys the man's eye, they shall cut off his
  hand
• Laws of Hammurabi, Babylon, BC 1792

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Root-cause analysis of major airline events

• Failure to follow accepted procedures
• Misinterpretation of instruments
• Incorrect decisions
• Ignoring advice from colleagues
• Failure of team working
• Equipment failure
• Pilot error

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Themes from systematic review of the data

• High proportion of incidents reported relate to
  Trust maternity trigger list categories
• Following these the top five themes are
• Communication
• Staffing levels
• Medication
• Equipment
• Patient ID

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Reasons Swiss cheese model
some holes due to active failures
hazards
other holes due to latent conditions
losses
defences. barriers and safeguards
James Reason 1997
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System Approach

• Wider in its remit
• more open
• based on concept of system failures
• Different outcome for the individual
• more likely to produce solutions
• reduce the chance of recurrence.
• requires trusting environment
• a no blame approach

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Systems Approach

• More comprehensive covering
• The person
• Team
• Procedure
• Environment
• Organisation

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Systems Approach

• Not
• who made a mistake
• but
• how and why have the defences failed

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Solution
We cant change the human condition, but we can
change the conditions under which humans
work James Reasons
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Defences, barriers, and safeguards

• Technical
• alarms, physical barriers, automatic shutdowns
• Human
• doctors, midwives, administrators
• Documentation
• guidelines, standard operating procedures
• Act to
• prevent error
• protect the patient
• Defences are mostly successful
• but not infallible.

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Safety

• Driving is safer
• Design
• Speed limits
• ABS
• Safety
• Car design
• Seat belts
• Airbags
• We are not better drivers

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Increasing the number of Barriers to prevent
Patient Safety Incidents
Cheddar Cheese
Swiss Cheese
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Guidelines

• Keep them simple
• For routine things
• Use checklists
• Use audit of practice

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Are they effective?

• The distribution of methodologically sound
  clinical guidance does not, however, ensure
  implementation
• The Obstetrician Gynaecologist, 2001, p93

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Guidelines

• Too many
• Too complicated
• End unto themselves
• Job is done
• Not proven or validated

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Yorkshire Guidelines

• Consensus guidelines
• Obstetricians and Anaesthetists
• All units in Yorkshire
• Commenced May 1997
• By 1999, all units using
• Regional audit of cases
• Each hospital auditing own cases
• Regional co-ordination
• Collection of data

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ICU admissions in Yorkshire
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Airline industry similar to medicine

• requires concentration
• long periods of little activity
• sudden emergencies
• instant decision making
• team working which is interdependent

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In Medicine

• Experts often not present at time of crisis
• (a latent failure)
• be aware of the possibility of failure
• be prepared to recognise and recover
• Assess possible risks
• risk assessment
• Rehearsing familiar scenarios
• Drills
• Common sense training

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Drills and Skills

• Teach basic skills
• For all
• Multidisciplinary
• Team working
• Update

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Airline industry

• Guidelines for the routine
• Check lists
• Drills for emergencies
• Experience for the unusual
• If they make a mistake - they die too

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Designing out faults

• Copied from industry
• Assess the environment leading to the event
• Design solutions
• Training/supervision
• Design equipment/Hospital
• Encourage change in behavior
• (Guidelines)

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JFK International terminal mens restrooms
what would you do?

• a) periodically plot spillage area on an X-bar
  chart, look for special causes (audit)
• b) double the size of the fixtures (prevent)
• c) hire an attendant to monitor and reprimand
  less hygienic users (supervise)
• d) Hand out guidelines on entry to toilet

Source Wall Street Journal, used by John
Grout, NPSA Seminar, 17 January 2003
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JFK International terminal mens restrooms

• e) etch the image of a fly on the porcelain -
  (Focus)

Source Wall Street Journal, used by John
Grout, NPSA Seminar, 17 January 2003
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Drug Administration
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Fully assess risk

• Past history
• Womans understanding of the risk
• Flagging of the problem
• Notifying
• (warning/planning)
• Guidelines

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What about Obesity?

• Increasing problem
• Not allowed to talk about it
• We do not weigh people any more
• Ignore the problem
• Wait for the disaster

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Approach to Risk
You need to know Min age is 12. Max weight is
16st. Min height is 4'11''. Unsuitable for
pregnant women or anyone unable to climb up into
the cockpit or fit in a standard car seat.
You need to know Full manual driving licence
required. As a guide max weight is 16st to 18st
and you should be between 5'1'' and 6'4''.
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Solution Development Processes

• Understanding the what, how and why
• Identify potential solutions
• Risk assess solutions
• Pilot and learn
• Implementation
• Evaluation and impact assessment

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Where are we now?

• Guidelines to inform
• Routine
• Checklists to focus
• Prompts
• Memory aids
• Care Bundles
• Drills for skills
• Regular
• For all
• Audit trail
• Prove what you do

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We need to share the learning from our mistakes
to try and stop them happening again ..
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