Issues of Patient SafetyQUB Third Year Introductory Week

Dr Noeleen DevaneyPatient Safety Lead,South Eastern Trust

Director,N Ireland CSCG Support Team

The Problem….

• Healthcare is not as safe as it should or could be

despite the best intentions of a dedicated and highly

skilled workforce

• Unintended harm and unnecessary deaths are the all

too frequent outcome of pressurized healthcare

systems

• 30-40% of patients do not receive care in line with

current scientific evidence

• 20% or more of care provided is either not needed or

potentially harmful

Patient Safety Incident

• Any unintended or unexpected incident/s that could or did lead to harm for one or more patients

Cost of Adverse Events

• Patients and families

• Healthcare staff -the second victims

• Financial-additional hospital stays alone estimated to cost £2000m annually in UK

The perception…

• If a doctor is highly trained and tries hard enough he/she will not make errors

• Errors and mistakes equate with personal failure and incompetence

Blame & Punish?

• the perfection myth – if we try hard enough

we will not make any errors

• the punishment myth– if we punish people

when they make errors they will make fewer of them

The reality…

• Human beings carrying out complex and risky procedures in our time pressurized healthcare organisations will make errors

• 95% of errors that cause harm involve conscientious competent individuals trying hard to achieve a desired outcome –only 5% of harm is caused by incompetence or poorly intended care

• errors/mistakes do not imply personal failure or incompetence

What is Human Error?

‘We all make errors - irrespective of how much

training and experience we possess, or how motivated we are to do it right’

(in Reducing error and influencing behaviour - HSG48)

We all make mistakes

Or support & learn?

Person v System Approach

• Person approach- focuses on the unsafe act, ‘name and shame’ individuals

• System approach- errors seen as consequence of unsafe systems; aim is to build defences and safeguards- robust systems that protect patients from harm

• Just culture –balanced approach, clarification of accountability

from R Resar, Institute for Healthcare Improvement

PARISIN THE

THE SPRING

Factors Contributing to Human Error

• Environmental Factors– Light– Noise and Vibration- Alarms!– Temperature– Humidity– Equipment layout and design– Physical environment

Factors Contributing to Human Error

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

Why things go wrong

• Failure to recognise

• Failure to rescue

• Failure to plan

• Failure to communicate

• Variation in medical practice (ie inappropriate variation not determined by patient need)

Common types of Medical Error

• Medication error –the most common single preventable cause of patient injury

• Missed and delayed diagnosis –eg failure to recognise a patient is seriously ill

• Perioperative –eg needless infection, wrong site, wrong side, wrong patient, lack of DVT prophylaxis

Key risk areas for junior doctors (examples)

• Errors in patient identification, clinical details on request forms, mislabelled samples – can lead to misdiagnosis, incorrect treatment, unnecessary delay or even transfusion error

• Failure to minimise HAI –handwashing• Incorrect drug prescription including transcribing

errors• Failure to diagnose correctly and delay in

diagnosis

Improving Patient Safety

• Minimise errors/prevent adverse events• Detect those that occur and mitigate before they

cause harm ( prevent adverse event)• Make any adverse events visible- speak up• Mitigate against the effects when adverse events

occur• Organisations need an explicit focus on a Safety

Environment

Fundamental Components of a Safety Environment

• Effective teamwork and collaboration between disciplines

• Structured systems

• Open communication surrounding errors and shared learning

• Full patient involvement

Structured systems

• Help ensure protection against error • Respect for these systems is crucial• Low tech systems include written guidelines,

protocols, standardised forms for completion, reminders, visual prompts

• High tech systems include infusion pumps, bar coding, computerised medication systems

• Anaesthetics has highly standardised systems and it is no coincidence that anaesthetics is the safest healthcare specialty

Standardisation

• Reduces unacceptable variation• Reduces potential for error• Makes care safer• Examples in use in N Ireland include

Medication on Admission Reconciliation Form, Care Pathways, EWS chart, Communication tools such as SBAR, Prevention of DVT proforma, Reducing Surgical Site Infection documentation etc etc

Medication Reconciliation

• Medication errors are the single most common cause of harm in any hospital setting

• 46% of all medication errors occur at transition points

• Medication reconciliation ensures that patients receive all intended and no unintended medications following transitions in care locations

• Medication on admission (MOA) reconciliation form completed on admission

Early Warning Score chart

• Records standard patient observations

• Generates an “at risk score”

• Indicates timescale for medical review

• Nurse may utilise a specific communication tool –SBAR-when seeking medical assistance

Communication for junior doctors

• Medical notes, care pathway, prescribed forms- write clearly!

• Listen to patients/relatives

• Multidisciplinary team• General Practitioner• Handovers

• Patient safety concerns-speak up!

• Incident reporting (near misses as well as adverse events)

• Ask for help sooner rather than later –don’t take risks by leaving it too late

SBAR

• Situation- what is happening at present time

• Background- circumstances leading up to situation

• Assessment- what I think the problem is

• Recommendation- what I think should be done to correct the problem

Ask Me 3

• Quick effective communication tool

• Three simple but essential questions that patients should be encouraged to ask in every health care interaction– What is my main problem?– What do I need to do?– Why is it important for me to do this?

Healthcare Associated Infection

• Major cause of needless morbidity and mortality• MRSA particularly problematic and C difficile increasing• By far the principal mode of spread is via the

contaminated hands of caregivers• Even casual contact with the infected patient or their

immediate environment can contaminate the caregivers hands –MRSA can survive for hours/days on table tops, bedrails etc

• Gloves provide some protection but hands are often contaminated in the process of removing gloves

Hand Hygiene

• Of pivotal importance in preventing the transmission of MRSA from patient to patient, even if the patient is on contact/barrier precautions and gloves are worn

• Alcohol hand rubs rapidly kill bacteria including MRSA but have no effect on C Difficle

• Personal equipment such as stethoscopes, if inadequately disinfected, can transmit MRSA

• Appropriate technique necessary

HEALTHCARE SYSTEMS

The Real World: Swiss Cheese

Defencesin depth

Other 'holes'due to latent

conditions

Some 'holes'due to active

failures

DANGER

From Reason 1997

A Tale of Two Cheeses

Emmental Cheese Havarti CheeseSource: Larry Veltman, M.D. Chairman, Department of Obstetrics and GynecologyProvidence St. Vincent Medical Center, Portland, Oregon

Clinical and Social Care Governance

• The framework through which HPSS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care

• Students need to understand the key components of Clinical and Social Care Governance (CSCG)

Key components of CSCG-1• Recognition of the crucial role of patient involvement in

delivering a safe, high quality service• The importance of evidence-based care in reducing

unacceptable variation in health care• The necessity to keep up to date• Individual accountability and “speaking up” as part of a

just culture• The importance of risk assessment and risk

management including adverse incident/near miss

reporting and complaints management

Key components of CSCG-2

• The imperative of learning lessons from what has gone wrong and addressing deficiencies so as to prevent reoccurrence

• The principles of audit and the necessity to “close the loop” (real time data best)

• Appraisal and professional regulation

Safer Patients Initiative• Downe and Lagan Valley Hospitals in Phase 1 (2004-2006)• RVH/ Mater and Antrim Area/Causeway hospitals in Phase 2

(2006-• Change package addressing 5 clinical areas

– Medicines Management– Infection Prevention and Control– Peri-operative Care– Critical Care– Care on General Wards

• Utilise improvement science and structured systems that minimize avoidable harm and take account of human factors

Sources of information

Institute for Healthcare Improvement website: www.ihi.org

National Patient Safety Agency website: www.npsa.nhs.uk

Noeleen.Devaney@setrust.hscni.net