Patient Safety: Where to now? Clinical Cultures

Dr Bernadette Eather NSW Director Patient Safety, CEC

Patient Safety- Where to now? • Safety Culture • Identification

– Data triangulation – Reporting

• High reliability • Safety II • Human factors/team work training • Focus on microsystem

What is safety culture? The complex framework of national,

organisational and professional attitudes and values within which groups and individuals

function that influence the safety of an organisation

Or

The way things are done around here

•(Helmreich & Merrit, 2001; Sexton, et al, 2003)

Characteristics of Safety Culture • Leadership commitment • Open & frequent communication (trust) • A just culture • Robust systems • Organisational learning • Team work • Awareness

Patient Safety Leaders: • Understand risk • Take action to mitigate patient risk • Are proactive • Report • See a problem and don’t ignore it • Don’t blame individuals • MAKE CHANGES to transform the workplace

Patient Safety II

• High reliability – An organisational structure and team-work

based safety culture so that inevitable human mistakes do not lead to patient harm. This methodology differs from previous quality and safety efforts, in that it simultaneously emphasises interprofessional interventions, behavioural changes, structured leadership, and culture shifts towards a culture of safety as a core value…

High performing health care • Organisational design- standardise practice,

reduce complexity, learn from mistakes • Organisational work- commitment to safety,

blame free, resources, encourage collaboration

• Organisational focus- preoccupation with potential failure, focus on near miss, teams, deference to frontline expertise

Content

Clinical incidents notified in IIMS by Actual SAC rating, January 2011 - June 2015

IIMS Clinical Incident Monthly Notifications 2005 – 2015

400050006000700080009000

100001100012000130001400015000160001700018000

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Axis

Titl

e

NSW Clinical Incident Notifications 2010-2015

2010

2011

2012

2013

2014

2015

Linear (2015)

Increased reporting rate of 5% each year

2015Jan-Jun Jul-Dec Jan-Jun Jul-Dec Jan-Jun Jul-Dec Jan-Jun Jul-Dec Jan-Jun

SAC 1* 269 309 290 308 306 302 252 262 238SAC 2 1,269 1,411 1,258 1,378 1,285 1,261 1,401 1,424 1,342SAC 3 29,059 30,688 30,355 32,675 33,849 34,524 36,007 39,343 39,462SAC 4 32,869 34,775 36,085 37,212 37,652 40,264 39,213 41,899 42,831No SAC Allocated 2,994 3,752 3,619 3,595 2,079 2,884 3,034 1,998 2,926TOTAL 66,460 70,935 71,607 75,168 75,171 79,235 79,907 84,926 86,799

SAC Rating 2011 2012 2013 2014

Clinical Management RCAs

• Total of 443 Clinical Management RCAs received January 2015 – June 2016

• Of the 443 RCAs, 93 (21 per cent) were allocated specific service Emergency (ED)

11

Clinical Management RCAs

12

1.08

1.08

1.08

3.23

3.23

3.23

3.23

4.3

4.3

6.45

7.53

7.53

9.68

9.68

15.05

19.36

0 2 4 6 8 10 12 14 16 18 20Percentage

Local Health Districts as a percentage of ED RCAs January 2015 - June 2016

Clinical Management RCAs

13

4.3

7.53

13.98

23.66

31.18

0 5 10 15 20 25 30 35

Death following fall

Non-preventable outcome

Diagnosis - delayed

Treatment - inadequate

Diagnosis - missed

Percentage

Top five Principle Incident Types as a percentage of ED RCAs January 2015 - June 2016

The PITs of Diagnosis – missed and Diagnosis – delayed represent 45.16 per cent of RCAs from specific service ED

Clinical Management RCAs

14

DP – Deteriorating Patient *multiple responses are allowed

12.9

15.05

17.2

17.2

20.43

28

30.11

33.33

57

65.6

0 10 20 30 40 50 60 70

Acute coronary syndrome

D/P - inapp/delayed response to esc

D/P - delay/failure to escalate

eMR

Sepsis

BTF charts/altered criteria

Acute abdominal pain, incl. AAA

ED representation

D/P - failure to recognise

Out of hours presentation/admission

Percentage

Top 10 Clinical Risk Groups* as a percentage of ED RCAs January 2015 - June 2016

The recognition and management of deteriorating patients is a significant patient safety issue.

Clinical Management RCAs

15

29.03

30.11

35.48

35.48

41.94

44.09

63.44

69.89

73.12

75.27

0 10 20 30 40 50 60 70 80

Supervision - Support inadequate

Environment - Activity

Obs & Monitoring - Physical/physiological obs inadequate

Policy/GL - Not implemented

Obs & Monitoring - Sig not recognised/responded

Care planning - Care coordination

Communication - Inadequate between care providers

Communication - Documentation inadequate

Assessment - Physical health

Care planning - Inadequate care plan

Percentage

Top 10 System Factors* as a percentage of ED RCAs January 2015 - June 2016

*multiple responses are allowed

Communication and Care planning are prominent issues in the delivery of safe and reliable patient care

Contributing factors Problems with communication remain the single most frequent cause of serious adverse events • Shift handovers • Handovers between teams • Ward/Department transfers • Inter-hospital transfers

Communication problems

• Doctor/nurse interactions –Different terminologies – “Going Off” •Different expectations •Recipients

• Medication orders •Similar names/different medications •Lasix and Losec

Human Factors • We all have different skills • We all think differently • We perform tasks based on experience • Individual or team level

How we make decisions

Control modes

Situations

Rule-based Trained-for problems

Mixed

Skill-based Routine

Automatic

Knowledge- based

Novel problems

Conscious

Skill-based slips

and lapses

Errors

Attentional slips of action

A common lapse

? The cure

Skill-based slips and lapses

Errors

Attentional slips of action

Memory lapses

Skill-based slips and lapses

Errors

Attentional slips of action

Memory lapses

Rule-based mistakes

Knowledge-based mistakes

Mistakes

rejected

False hypothesis error

Incorrect hypothesis

Allnutt M, 1983

Tailored to fit

New information

Air New Zealand Flight 905, 1979

Safety Huddles - Why Increase and maintain situational awareness

– Improves overall leadership awareness of the status of front-line operations

– Provides timely recognition and resolution of problems that impact outcomes

– Provides for alignment and focus of the leadership team around safety and key operational issues

An effective daily safety huddle: – Communicates the urgency of resolving safety issues and critical

situations – Allows the team to plan for the unexpected – Allows team members’ needs and expectations to be met – Uses concise and relevant information to promote effective

communication

Leadership, culture, partnerships

• Leadership programs • Coaching • Increase focus/awareness • Best practice examples • Universities • Consumers

• Exec walkrounds • Safety huddles • Handover/communication • Team based training • Target local programs

Priorities

Outputs of high reliability

Questions? Dr Bernadette Eather

Director Patient Safety | Clinical Excellence Commission p. (02) 9269 5506 | m. 0413316591|

bernadette.eather@health.nsw.gov.au

Level 17, 2-24 Rawson Pl Haymarket NSW 2000

Locked Bag 8 Haymarket NSW 1240

Tel: +61 2 9269 5500

www.cec.health.nsw.gov.au