Transcript Clinical Risk Management

International Perspectives
Feedback from the review board
Charles Vincent
Clinical Risk Unit
University College London
Clinical Risk Unit
University College London
Adverse event studies
 3-16%
adverse event rate in US and
Australia
 10.0
% cases with adverse events in UK
 10.7
% adverse event rate
 30%
events lead to moderate or greater
impairment to patient

Half of adverse events cases preventable
Clinical Risk Unit
University College London
To err is human: The Institute of
Medicine Report
 Establish
a national focus to create
leadership, research tools and protocols
 Identifying and learning from errors
through mandatory & voluntary reporting
 Raising standards and expectations for the
improvement of safety
 Creating safety systems inside healthcare
organisations through implementation of
safe practices at delivery level
Clinical Risk Unit
University College London
Recommendations from the IOM
Report
 Creation
of a Centre for Patient Safety
– Set national goals
– Develop knowledge and understanding
 Identifying
and learning from errors
– Nation-wide mandatory reporting system
– Encouraging voluntary reporting systems
– Legislation to protect safety data
Clinical Risk Unit
University College London
Recommendations from the IOM
Report
 Performance
standards and expectations
– Focus greater attention on patient safety for
» health organisations
» health professionals
– Drug packaging and drug names
 Implementing
safety systems
– Establishing patient safety programmes
– Implementing proven medication safety
practices
Clinical Risk Unit
University College London
An Organisation with Memory
Recommendations
 Introduce
a national mandatory reporting
scheme for serious adverse events
 Encourage a reporting and questioning
culture
 Introduce a single overall system for
analysing and disseminating lessons
 Make better use of existing sources of
information
Clinical Risk Unit
University College London
An Organisation with Memory
Recommendations
 Improve
the quality and relevance of
adverse event investigations and inquiries
 Undertake a programme of basic research
 Make full use of NHS information systems
 Act of ensure lessons learned quickly
Clinical Risk Unit
University College London
An Organisation with Memory
Recommendations
 Identify
and address specific categories of
serious recurring adverse events
– Reduce deaths from maladministered spinal
injections to zero
– Reduce negligent harm in obstetrics by 25%
– Reduce by 40% serious errors in use of
prescribed drugs
– Reduce suicide by hanging in mental health
patients to zero
Clinical Risk Unit
University College London
An Organisation with Memory
Learning from adverse events in the British NHS
PAST
 Fear of reprisals
common
 Individuals
scapegoated
 Individual training
dominant
 Attention focuses on
individual error
Clinical Risk Unit
University College London
FUTURE
 Generally blame free
reporting
 Individuals held to
account
 Team-based training
more common
 Systems approach to
hazards & prevention
An Organisation with Memory
Learning from adverse events in the British NHS
PAST
 Lack of awareness of
risk management
 Short term fixing of
problems
 Adverse events
regarded as `one-offs’
 Lessons seen as only
relevant for team
Clinical Risk Unit
University College London
FUTURE
 Risk & safety training
provided
 Emphasis on sustained
risk reduction
 Potential for repeated
events recognised
 Lessons may be
relevant to others
National Centre for Patient
Safety in Switzerland (NCPS)
 Identify
existing patient safety initiatives
 Establish central database of resources and
information and research programme
 Enhance methods of investigation and
analysis
 Disseminate lessons learned and initiate risk
reduction programmes
 Provide support and guidance for patients
and staff
Clinical Risk Unit
University College London
Central themes of NCPS
 Building
on international work, but
developing uniquely Swiss programme
 Broad strategy and positive approach to
patient safety
 Systems thinking and interventions
 Strong emphasis on organisational culture
 Unique focus on supporting and caring for
patients and staff
Clinical Risk Unit
University College London
Key tasks in Phase II
 Consultation
and gaining support from
patients and professionals
 Integration of patient safety with broad
quality initiatives
 Debate on the need for an open culture
 Balance of immediate improvements and
long term re-design of systems
 The role of financial and legal pressures
Clinical Risk Unit
University College London
Looking to the future
 Potentially
the first National Patient Safety
Centre in Europe
 Balancing local and national systems
 Development of international links within
healthcare and with other industries
 Maintaining a positive patient centred
approach
Clinical Risk Unit
University College London