Transcript November Safety Meeting 2003

Incident Reporting in Healthcare
and the Associated Human Factors
Issues
Sarah Scobie
Head of Analysis and Feedback
Melinda Lyons
Human Factors Lead
Presentation today
• The National Reporting and Learning
Service
• Healthcare’s achievements in incident
reporting
• The Human Factors issues in incident
reporting in healthcare
Purpose of the Reporting and
Learning System
 Learning for safety improvement
 Hazard and risk identification
 New and emerging hazards
 Highlighting unsolved problems
 Supporting reporting organisations with local
reporting
 Locally, each NHS organisation using data for
patient safety and risk management
Reporting and
Learning Cycle
•Know what the problems are
•Understand which are most
important and why they
happen
•Inform solutions and
recommendations to prevent
future harm
•Assess the difference
How does it collect incidents
• Voluntary, confidential national system
• Commenced Nov 2003 – over 4 million reports so
far
• Covers all health sectors
• Every severe and death incident individually
reviewed for national learning
• Undergoing continuous improvement
Local Risk
Manageme
nt
System
Service
eForm
Open
Access
eForms
WWW
NHS Net
99% incidents
Encrypted
traffic
Reporting and Learning System
Secure
Database
Data cleansing
Cleansed
Database
Analysis
and
feedback
Numbers…
Chart 1: Number of incidents reported and organisations reporting by quarter, October
2003 - December 2008
Number of incidents
reported
Average proportion of trusts reporting
per month
300,000
80%
Incidents submitted
Average proportion of trusts reporting per month
70%
250,000
60%
200,000
50%
150,000
40%
30%
100,000
20%
50,000
10%
0
0%
Oct - Jan - Apr - Jul - Oct - Jan - Apr - Jul - Oct - Jan - Apr - Jul - Oct - Jan - Apr - Jul - Oct - Jan - Apr - Jul - Oct Dec Mar
Jun Sep Dec Mar
Jun Sep Dec Mar
Jun Sep Dec
Mar
Jun Sep Dec
Mar
Jun Sep Dec
2003 2004 2004 2004 2004 2005 2005 2005 2005 2006 2006 2006 2006 2007 2007 2007 2007 2008 2008 2008 2008
April 07
To
March 08
April 07
to
March 08
April 07
To
March 08
… and text
“Cardiac arrest. Patient had mouth full of stomach contents…
Both portable suctions not working. Aspiration.”
•Provides essential information for learning from individual
incidents
•Provides case studies to illustrate points which front-line
clinicians relate to
•Brings incidents and learning alive
1500
Systematic review of NRLS death & severe incidents
Systematic review of STEIS reports
Ad hoc incident / issue reports e.g. coroners, clinicians
50
Incidents & issues considered by
the Weekly Response Group
20
Issues followed up
with mini-scope
e.g. NRLS search,
basic literature
search
4
Fullscope
1
RLS based products ...
Products & activities
Ongoing projects
for clinical teams
National Institute
for Clinical
Excellence (NICE)
Resuscitation
Council
National Confidential
Enquiry into Patient
Outcome and Death
(NCEPOD)
* correct site burr holes in emergency neurosurgery * delayed diagnosis
of head injury in patients affected by alcohol * sudden collapse in
orthopaedic surgery related to cement and fat embolism * omission of
urgent antibiotics in sepsis and neutropaenia * resuscitation in mental
health settings, including management of choking and illicit opiate use *
diagnostic delay where minor head injuries lead to significant harm in anticoagulated patients * nasogastric feeding safety in patients with anorexia
nervosa * incorrect insertion of central lines * collapse in hospital
grounds and the responsibilities of hospital and ambulance service
staff * transport for patients in urgent need of transfer between hospitals *
correct lens insertion in cataract surgery * patients with arterial disease
whose circulation is compromised by anti-embolism stockings * access to
emergency gastroscopy out-of-hours * readmission after day surgery *
non-invasive ventilation outside high dependency environments * portable
syringe drivers in terminal care * female catheters causing urethral
trauma if inserted in males * Awareness due to lack of non-return valve
on giving set (TIVA) * administration errors when medication supplied in
compliance aids * safe storage of emergency medications in staff response
vehicles * HIV screening and treatment in maternity care * management of
oxygen therapy * over-provision of intravenous fluids * wrong side burr
holes / craniotomy *
Rapid Response
Report
Royal College of
Ophthalmologists
Medicines &
Healthcare
products
Regulatory Agency
(MHRA)
Royal College of
Anaesthetists
Chest drains
• Trigger incident – patient died from perforated liver
after drain inserted Feb 08
• RLS database : 12 reported patient deaths + 15
serious harm Jan 05 - March 08
• + 9 serious incidents from MHRA re problems with
equipment
• Go back to trusts for more information – RCAs
• Key learning – junior doctors without supervision, poor
positioning (without ultrasound), unfamiliar with
equipment
Actions
• Report May 2008 developed
with input of chest
physician/British Thoracic
Society
• Clear actions including use of
ultrasound (NICE 2006)
• Longer term action includes
work by MHRA (concern re
length of dilators) and revised
clinical guidelines from British
Thoracic Society
• Evaluation in 2009 but
informal feedback suggests
widespread support eg
purchase of portable
ultrasounds
Challenges
Under-reporting
Closing the
loop
Analytic methods
Priority setting
Actionable learning
What are the biggest challenges?
• “Extracting the important data - what are the real
issues that impact on safety, how can we
analyse in a meaningful manner, other than
simple 'number' crunching.”
• “Relies on events being reported; easy to miss
recovered incidents as staff see it as part of their
skill to do so - may consider don't have time to
then report, especially if no harm to the patient.”
• “Conflicting demands on existing resources, in
respect of support staff, reporters etc”
Direction
• Embedding and engaging
• Trial of specialty reporting
• Data mining
And not to forget those human
factors….
• Human Factors in the analysis
•
•
•
•
Awareness of Human Error
Awareness of Equipment design
Awareness of Workload
Supporting clinical decisions and education about
biases
And not to forget those human
factors….
• Human Factors in the solutions
•
•
•
•
Equipment and Environment Design
Training and Education
Protocols and Checklists
Supporting a “just culture”
And not to forget those human
factors….
• Education of the value of human factors (it’s not
just teamwork!)
• The role in implementation and stakeholder
engagement
• Recognition of human errors – even in the most
well-meaning of patient safety efforts…
• Validation of changes / decisions – did they really
make it more safe?
www.npsa.nhs.uk
[email protected]
[email protected]