Transcript Issues of Patient Safety QUB Third Year Introductory Week

Issues of Patient Safety
QUB Third Year Introductory Week
Dr Noeleen Devaney
Patient 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’
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
PARIS
IN THE
THE SPRING
from R Resar, Institute for
Healthcare Improvement
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
DANGER
Some 'holes'
due to active
failures
Defences
in depth
From Reason 1997
Other 'holes'
due to latent
conditions
A Tale of Two Cheeses
Emmental Cheese
Source: Larry Veltman, M.D.
Chairman, Department of Obstetrics and Gynecology
Providence St. Vincent Medical Center, Portland, Oregon
Havarti Cheese
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 (20042006)
• 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
[email protected]