Safety First Accidents a Close Second

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Safety First Accidents a Close Second!

• Dr. Maureen Baker CBE DM FRCGP
• Honorary Secretary

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(No Transcript)
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Overview

• Background to the patient safety movement
• An Organisation with a Memory
• Seven Steps to Patient Safety
• Future developments

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Some definitions

• Patient Safety freedom from accidental harm to
  individuals receiving healthcare
• Patient Safety Incident an episode when
  something goes wrong in healthcare resulting in
  potential or actual harm to patients

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Is there a problem?
Studies based on retrospective analysis of
medical records

• Harvard study 1991 (Lucien Leape) adverse event
  rate in hospitalisations of 3.7 of which two
  thirds were errors
• Australian study 1995 (Ross Wilson) adverse
  event rate 16.6
• British study 2001 (Charles Vincent) adverse
  event rate of 10.8

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To Err is Human (Institute of Medicine 1999)

• As many as 98,000 people die each year in USA
  from medical errors that occur in hospitals. That
  is more than die in RTAs or from breast cancer or
  AIDS. Medical error is fifth leading cause of
  death in USA

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An Organisation with a Memory (CMO, 2000)

• The NHS is doomed to make the same mistakes over
  and over again as we have no way of learning from
  when things go wrong

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Disasters in other industries

• Herald of Free Enterprise
• Hillsborough
• Sinking of Marchioness on Thames
• Bhopal

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Learning from when disasters happen

• Complex set of interactions
• No single causal factor
• Combination of local conditions, human
  behaviours, social factors, organisational
  weaknesses

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Human Error (Reason, 1990)

• Humans are fallible and errors are inevitable
• Systems approach takes holistic view of causes of
  failure
• Cannot change the human condition but can change
  conditions in which people work and minimise
  opportunities for error

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Reasons Swiss Cheese Model
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An Example
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Systems Approach in Healthcare

• As many as 70 of adverse incidents are
  preventable
• Errors can be minimised, but never completely
  eliminated
• Rarely single, isolated cause of error attempts
  to prevent errors need to address systems as a
  whole

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Safety Critical Industries with Safety Approach

• Aviation
• Railways
• Oil and Gas
• Construction
• Nuclear
• Military

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Learning from failure

• The NHS is not unique other sectors have
  experience of learning from failures which is of
  relevance to the NHS
• Sir Liam Donaldson in
• Organisation with a Memory

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Systems for Learning from Experience Aviation

• Accident and serious incident investigations
• Confidential Human factors Incident Reporting
  Programme (CHIRP)
• Company Safety Information Systems
• Crew Resource Management

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The Need for Action in Healthcare

• Unified mechanisms for reporting and analysing
  examples of when things have gone wrong
• Development of a more open culture in which
  errors or service failures can be admitted
• Lessons must be identified, active learning must
  take place and necessary changes must be put into
  practice
• Healthcare professionals must appreciate the need
  to think systems in learning from errors, as
  well as in prevention through risk management

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The National Patient Safety Agency

• Established in 2001
• Relates to England and Wales
• Responsible for National Reporting and Learning
  System (NRLS)
• Previously produced Patient Safety Alerts
• Now is developing systems of Rapid Responses
• Produced guidance to the NHS on patient safety
  Seven Steps to Patient Safety

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Reported incidents by type (NPSA, April 2006
March 2007)
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Reported degree of harm
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Seven Steps to Patient Safety
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The Steps
Step 7 - Solutions to reduce harm
Step 6 - Learn and Share Lessons
Step 5 - Patient involvement
Step 4 - Promote Reporting and Learning
Step 3 - Integrated Risk Management
Step 2 - Lead and support your staff
Step 1 - Build a Safety Culture that is open and
fair
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Step 1 - Build a Safety Culture that is Open and
Fair

• Organisations, practices, teams and individuals
  have constant and active awareness of potential
  for things to go wrong
• Being open and fair means sharing information
  freely with patients and families balanced by
  fair treatment for staff when things go wrong
• Incidents are linked to the system in which an
  individual works

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Safety Culture

• NPSA A safety culture is where organisations,
  practices, teams and individuals have a constant
  and active awareness of the potential for things
  to go wrong. Both the individuals and the
  organisation are able to acknowledge mistakes,
  learn from them, and take action to put things
  right.
• Confederation of British Industry The way we do
  things around here

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Step 1 Best Practice

• Dont expect perfection from humans use systems
  to support human decision making
• Establish reporting systems for errors and
  adverse events (practice local national)
• Assess your culture by undertaking a practice
  safety culture audit, eg MaPSaF

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Step 2 - Lead and Support Staff

• Delivering patient safety needs motivation and
  commitment from clinical and managerial staff
• everyone has a responsibility for safety
• Leaders must be visible and active in leading
  patient safety improvements
• Staff and teams should be able to say if they do
  not feel that care is safe regardless of their
  position
• Some ideas patient safety champions safety
  briefings team briefings safety walkabouts

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Step 2 Best practice

• Leadership GPs and practice leaders have to own
  safety. Walk the walk
• Reflection How are we doing on safety?
• Training Run in-house and seek out external
  provision
• Promotion standing agenda item in clinical and
  business meetings

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Step 3 Integrate risk management activity

• Proactive
• Training in safety and risk
• Use risk assessment in major change management
  projects
• Review controls for minimising risk

• Reactive
• Incident reporting and analysis
• Significant event audit at team or unit level
• Root cause analysis at organisational level
• All of the above methods can be integrated

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Step 3 Best Practice

• Regular and embedded SEA in practice
• Sharing the learning from SEA
• Active and willing participation in other
  reactive methods, eg RCA
• Active participation in reporting systems Should
  we report this?
• Embrace risk assessment methodology identify
  and manage your risks

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Step 4 Promote reporting

• Reporting of patient safety incidents provides
  the opportunity to ensure that learning from what
  happened to one patient can reduce the risk of
  the same thing happening to another patient
• Reporting should be simple, timely, confidential
  (?anonymous), and have feedback mechanisms

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Step 4 Best Practice

• Report locally
• Learn and share locally
• Report nationally
• Involve patients and public in reporting and
  learning

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Step 5 Involve and communicate with patients
and the public

• Patients expertise and experience can be used to
  identify risks and devise solutions to patient
  safety problems
• Staff need to include patients in identifying
  risks and in helping to protect themselves from
  harm
• Being open when things have gone wrong can help
  patients cope better afterwards

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Step 5 Best Practice

• Actively involve patients in safety culture and
  activity eg section on safety in annual reports,
  patient reps in risk assessments
• Seek patient views and comments
• Be open when things go wrong (Being open tool
  from NPSA available online)

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Step 6 Learn and share safety lessons

• Root cause analysis
• Intensive technique
• Usually for most serious incidents (deaths or
  multiple cases of harm)
• Normally at organisational level
• Requires trained facilitators
• Learning can be shared

• Significant Event Audit
• Developed in general practice and promoted by
  RCGP
• Team based
• Can link to conventional audit
• Can be themed
• Powerful driver for change
• Learning can be shared

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Step 6 Best Practice

• Regular structured SEA meetings
• Respond quickly when there are important events
  or when high risks are identified
• Involve patients
• Learn lessons and put learning into practice
  dont be doomed to see the same event happening
  over and over again

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Step 7 Implement solutions to prevent harm

• Design systems that make it easy for people to do
  the right thing and difficult for them to do the
  wrong thing
• Solutions that rely on physical barriers are far
  more effective than those that rely on human
  behaviour and action
• Solutions should be risk assessed, evaluated and
  sustainable in the long term

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Step 7 Best Practice

• Actively consider solutions in SEA meetings
• What have others done?
• What ideas can we get from staff and patients?
• Formal risk assessment of solutions
• Share your solutions with others

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Where are we now?

• Increased awareness
• Enlistment of stakeholders
• Safety campaigns 100,000 Lives in USA
• Leadership - Safety First, Dec 2006
• Translating to action?
• What are they actually doing?
• WHO Safer Surgery
• What is happening in New Zealand?

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From Seven steps to Next steps

• Need safety culture to tackle safety problems,
  e.g. Infection control needs ALL Seven Steps
• Professional understanding and ownership
  especially safety culture and human factors
• Work with safety professionals a pilot or an
  engineer on every Healthcare Board?
• Research and evaluation to demonstrate clinical
  and financial benefits