patient safety what should we be trying to communicate? making tomorrows doctors safer january 2011...
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Patient SafetyWhat should we be trying to communicate?
Making Tomorrows Doctors Safer January 2011
Charles VincentProfessor of Clinical Safety Research
Department of Surgical Oncology & TechnologyImperial College London
www.cpssq.org
Overview
Understanding patient safety What have we learned so far? Teams create safety So what should we try to communicate in
education and training?
Imperial Academic Health Sciences Centre
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
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
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)
Patient Safety in the UK
UK Department of Health, 2000
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
Epidemiology of harm
The unreliability of healthcare
Surgical Equipment Checks
0
20
40
60
80
100
120
SurgInstruments
op specificequip
diathermy suction
% C
he
ck
ed
YES
NO
Undre et al, 2006
Understanding why things go wrong
The safety paradox
Healthcare staff are:– Highly trained & motivated– Committed to their patients– Use sophisticated technology
Errors are common and patients are frequently harmed
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
Contributory factors: 7 levels of safety
Patient Task Individual staff Team Working conditions Organisational Government and regulatory
Vincent, Adams, Stanhope 1998
Teams create safety
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
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
Consultant Anaesthetist
Pump
Monitor
Ventilator
Anaesthetic Registrar
Pump Drains
Urine
Nurse
Nurse
ODA
CCC Reg / Nurse
Surgeon
Power
Multiple specialists
Complex tasks
Complex interfaces
Time pressure
Need for accuracy Catchpole et al, 2007
II Patient handover
Process Organisation
Task sequenceA rhythm and order to events
Task allocationTeam members have defined tasks
Leadership– Who is in charge
Discipline and composureExplicit communication strategies to ensure calm and organised atmosphere
Stages in process clearly defined
Ventilation: AnaesthetistsMonitoring: ODADrains: Nurses
Anaesthetist has overall responsibilityDefined moment for transfer to intensivist
Comms limited during equipment phaseOrder for briefing (Anes; Surg; Discuss;Plan)No interruptions
Pit Stop Handover
Catchpole et al, 2007
Performance improvements with new handover protocol
0
1
2
3
4
5
6
7
Before After
Number of Errors
0
2
4
6
8
10
12
14
Before After
Duration (mins)Information Omissions
0
1
2
3
4
Before After
Observation of 23 pre- and 27 post- handovers, balanced for operative risk
III Care bundles & organisational change
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
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
So what should we try to communicate?
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)
The essentials of patient safety
The human tragedies Scale of error and harm The safety paradox Reflecting on one’s 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
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)
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)
Clinical Safety Research Unitwww.csru.org.uk
Centre for Patient Safety & Service Qualitywww.cpssq.org
Further Information