Patient Safety What should we be trying to communicate?

1
Patient SafetyWhat should we be trying to
communicate?

• Making Tomorrows Doctors Safer January 2011
• Charles Vincent
• Professor of Clinical Safety Research
• Department of Surgical Oncology Technology
• Imperial College London
• www.cpssq.org

2
Overview

• Understanding patient safety
• What have we learned so far?
• Teams create safety
• So what should we try to communicate in education
  and training?

3
Imperial Academic Health Sciences Centre
4
Defining patient safety

• The avoidance, prevention and amelioration of
  adverse outcomes or injuries stemming from the
  process of healthcare
• Negative or positive
• Reactive or proactive
• An Aspiration Ambition
• One of a number of objectives
• The heart of quality

5
Consequences of serious adverse events for
patients families

• Death of neonates, children, adults
• Loss of womb in young women
• Untreated cancer, mastectomy
• Blindness
• Disability and handicap, children and adults
• Chronic pain, scarring, incontinence
• Profound effects on all aspects of their lives

Vincent, Young Phillips, 1994
6
Impact of mistakes

• I was really shaken. My whole feeling of self
  worth and ability was basically profoundly
  shaken
• I was appalled and devastated that I had done
  this to somebody
• My great fear was that I had missed something,
  then there was a sense of panic
• It was hard to concentrate on anything else
  because I was so worried (Christensen, 1992)

7
Patient Safety in the UK
8
UK Department of Health, 2000
9
(No Transcript)
10
Epidemiology of harm
Study Date of admissions Number of hospital admissions Adverse event rate ( admissions)
California Insurance Study 1974 20864 4.65
Harvard Medical Practice Study 1984 30195 3.7
Utah-Colorado 1992 14052 2.9
Australian 1992 14179 16.6
United Kingdom 1999 1014 10.8
Denmark 1998 1097 9.0
New Zealand 1998 6579 11.2
France 2002 778 14.5
Canada 2000 3745 7.5
11
The unreliability of healthcare
Undre et al, 2006
12
Understanding why things go wrong
13
The safety paradox

• Healthcare staff are
• Highly trained motivated
• Committed to their patients
• Use sophisticated technology
• Errors are common and patients are frequently
  harmed

14
Understanding why things go wrong

• Chain of events
• Complexity and contributory factors
• The importance of cumulative minor errors and
  deviations
• Tackling safety on many levels

15
Contributory factors 7 levels of safety

• Patient
• Task
• Individual staff
• Team
• Working conditions
• Organisational
• Government and regulatory

Vincent, Adams, Stanhope 1998
16
Teams create safety
17
I Reliability of ward care

• (1) How well do you understand the goals of care
  for this patient today?
• (2) How well do you understand what work needs to
  be accomplished to get this patient to the next
  level of care?
• Less than 10 of nurses or doctors could answer
  these questions

Pronovost et al, 2003
18
(No Transcript)
19
The Impact of Daily Goals

• Structured and organised care for each patient
• Reliability reducing the gap between what
  should be happening and what is actually
  happening
• Reduced length of stay from 2.5 to 1.3 days

Pronovost, 2003
20
II Patient handover
Catchpole et al, 2007
21
Process Organisation
Pit Stop
Handover

• Stages in process clearly defined
• Ventilation Anaesthetists
• Monitoring ODA
• Drains Nurses
• Anaesthetist has overall responsibility
• Defined moment for transfer to intensivist
• Comms limited during equipment phase
• Order for briefing (Anes Surg DiscussPlan)
• No interruptions

• Task sequence
• A rhythm and order to events
• Task allocation
• Team members have defined tasks
• Leadership
• Who is in charge
• Discipline and composure
• Explicit communication strategies to ensure calm
  and organised atmosphere

Catchpole et al, 2007
22
Performance improvements with new handover
protocol
Observation of 23 pre- and 27 post- handovers,
balanced for operative risk
23
III Care bundles organisational change
24
Decreasing catheter related bloodstream
infections

• Hand washing
• Full barrier precautions during the insertion of
  central venous catheters
• Cleaning the skin with chlorhexidine
• Avoiding the femoral site if possible
• Removing unnecessary catheters

• Median rate of infection per 1000 catheter days
  decreased from 2.7 at baseline to 0 at 3 months
• Mean rate at baseline decreased from 7.7 to 1.4
  at 16-18 months follow up

25
Care bundles organisational change

• A focus on systems
• Local ownership and engagement
• Encouraging local adaptation of the intervention
• Creating a collaborative culture
• Time and resources

Pronovost et al, 2008
26
So what should we try to communicate?
27
Becoming aware

• Communication in Emergency Care
• Tracking the process I just could not believe we
  were doing all this
• Observing the handover Staggering, jaw dropping
• Putting on my second hat (Krishna Moorthy)

28
The essentials of patient safety

• The human tragedies
• Scale of error and harm
• The safety paradox
• Reflecting on ones own environment
• The informal nature of many healthcare processes
• The many levels of influence and intervention
• The potential for simple changes
• That they can make a difference

29
Safety in clinical practice I

• I do not undertake any procedure unless I am sure
  I am competent in performing it or have adequate
  supervision.
• Senior clinicians say they want juniors to err on
  the side of safety yet many younger clinicians
  fear seeming weak. I make a point to reminding
  myself day after day that I want to be safe first
  and brave afterwards.
• Spending longer with patients explaining and
  discussing the risks and benefits of treatment
• Being obsessive about hand washing. I am now very
  aware of why we are asked to do this and so less
  irritated about the time it takes
• Having enough humility to recognize when you are
  stepping beyond your depth and willingness to ask
  for help

(Jacklin, Undre, Olsen)
30
Safety in clinical practice II

• Being more vigilant in terms of errors that occur
  in day to day practice which I may have missed in
  the past.
• Being willing to address loose ends rather than
  say this is not part of my problem.
• Involving the patient in their care. For example
  always asking the patient which side they thought
  they were having the operation.
• Being more explicit about my instructions,
  discussing everything I think or intend to do to
  with the patient
• At handover always summarising the situation,
  outlining the plan and being absolutely clear
  about what to monitor and at what point I want to
  be called

(Jacklin, Undre, Olsen)
31
(No Transcript)
32
Clinical Safety Research Unitwww.csru.org.ukCent
re for Patient Safety Service
Qualitywww.cpssq.org
Further Information