Promoting Excellence in Family Medicine

Safety First – Accidents a Close Second!

Dr. Maureen Baker CBE DM FRCGP

Honorary Secretary

Overview

Background to the patient safety movement

An Organisation with a Memory

Seven Steps to Patient Safety

Future developments

Some definitions

Patient Safety – freedom from accidental harm to individuals receiving healthcare

Patient Safety Incident – an episode when something goes wrong in healthcare resulting in potential or actual harm to patients

Is there a problem?

Harvard study 1991 (Lucien Leape) – adverse event rate in ‘hospitalisations’ of 3.7% of which two thirds were ‘errors’

Australian study 1995 (Ross Wilson) – adverse event rate 16.6%

British study 2001 (Charles Vincent) – adverse event rate of 10.8%

Studies based on retrospective analysis of medical records :

To Err is Human (Institute of Medicine 1999)

As many as 98,000 people die each year in USA from medical errors that occur in hospitals. That is more than die in RTAs or from breast cancer or AIDS. Medical error is fifth leading cause of death in USA

An Organisation with a Memory (CMO, 2000)

The NHS is doomed to make the same mistakes over and over again as we have no way of learning from when things go wrong

Disasters in other industries

Herald of Free Enterprise

Hillsborough

Sinking of Marchioness on Thames

Bhopal

Learning from when disasters happen

Complex set of interactions

No single causal factor

Combination of local conditions, human behaviours, social factors, organisational weaknesses

Human Error (Reason, 1990)

Humans are fallible and errors are inevitableSystems approach takes holistic view of causes of failureCannot change the human condition but can change conditions in which people work and minimise opportunities for error

Reason’s Swiss Cheese Model

An Example

Systems Approach in Healthcare

As many as 70% of adverse incidents are preventable

Errors can be minimised, but never completely eliminated

Rarely single, isolated cause of error – attempts to prevent errors need to address systems as a whole

Safety Critical Industries with Safety Approach

AviationRailwaysOil and GasConstructionNuclearMilitary

Learning from failure

“The NHS is not unique: other sectors have experience of learning from failures which is of relevance to the NHS”

Sir Liam Donaldson in

‘Organisation with a Memory’

Systems for Learning from Experience : Aviation

Accident and serious incident investigations

Confidential Human factors Incident Reporting Programme (CHIRP)

Company Safety Information Systems

Crew Resource Management

The Need for Action in Healthcare

Unified mechanisms for reporting and analysing examples of when things have gone wrongDevelopment of a more open culture in which errors or service failures can be admittedLessons must be identified, active learning must take place and necessary changes must be put into practiceHealthcare professionals must appreciate the need to ‘think systems’ in learning from errors, as well as in prevention through risk management

The National Patient Safety Agency

Established in 2001Relates to England and WalesResponsible for National Reporting and Learning System (NRLS)Previously produced Patient Safety AlertsNow is developing systems of ‘Rapid Responses’Produced guidance to the NHS on patient safety – ‘Seven Steps to Patient Safety’

Reported incidents by type (NPSA, April 2006 – March 2007)

Reported degree of harm

Seven Steps to Patient Safety

The Steps

Step 1 - Build a Safety Culture that is open and fair

Step 5 - Patient involvement

Step 3 - Integrated Risk Management

Step 2 - Lead and support your staff

Step 4 - Promote Reporting and Learning

Step 6 - Learn and Share Lessons

Step 7 - Solutions to reduce harm

Step 1 - Build a Safety Culture that is Open and Fair

Organisations, practices, teams and individuals have constant and active awareness of potential for things to go wrongBeing open and fair means sharing information freely with patients and families balanced by fair treatment for staff when things go wrongIncidents are linked to the system in which an individual works

Safety Culture

NPSA – A safety culture is where organisations, practices, teams and individuals have a constant and active awareness of the potential for things to go wrong. Both the individuals and the organisation are able to acknowledge mistakes, learn from them, and take action to put things right.Confederation of British Industry – The way we do things around here

Step 1 – Best Practice

Don’t expect perfection from humans – use systems to support human decision making

Establish reporting systems for errors and adverse events (practice; local; national)

Assess your culture by undertaking a practice safety culture audit, eg MaPSaF

Step 2 - Lead and Support Staff

Delivering patient safety needs motivation and commitment from clinical and managerial staff

everyone has a responsibility for safety

Leaders must be visible and active in leading patient safety improvements

Staff and teams should be able to say if they do not feel that care is safe – regardless of their position

Some ideas – patient safety champions; safety briefings; team briefings; safety walkabouts

Step 2 – Best practice

Leadership – GPs and practice leaders have to own safety. Walk the walk

Reflection – ‘How are we doing on safety?’

Training – Run in-house and seek out external provision

Promotion – standing agenda item in clinical and business meetings

Step 3 – Integrate risk management activity

Proactive

Training in safety and risk

Use risk assessment in major change management projects

Review controls for minimising risk

Reactive

Incident reporting and analysis

Significant event audit at team or unit level

Root cause analysis at organisational level

All of the above methods can be integrated

Step 3 – Best Practice

Regular and embedded SEA in practice

Sharing the learning from SEA

Active and willing participation in other reactive methods, eg RCA

Active participation in reporting systems ‘Should we report this?’

Embrace risk assessment methodology – identify and manage your risks

Step 4 – Promote reporting

Reporting of patient safety incidents provides the opportunity to ensure that learning from what happened to one patient can reduce the risk of the same thing happening to another patient

Reporting should be simple, timely, confidential (?anonymous), and have feedback mechanisms

Step 4 – Best Practice

Report locally

Learn and share locally

Report nationally

Involve patients and public in reporting and learning

Step 5 – Involve and communicate with patients and the public

Patients’ expertise and experience can be used to identify risks and devise solutions to patient safety problems

Staff need to include patients in identifying risks and in helping to protect themselves from harm

Being open when things have gone wrong can help patients cope better afterwards

Step 5 – Best Practice

Actively involve patients in safety culture and activity eg section on safety in annual reports, patient reps in risk assessments

Seek patient views and comments

Be open when things go wrong (‘Being open’ tool from NPSA available online)

Step 6 – Learn and share safety lessonsSignificant Event Audit

Developed in general practice and promoted by RCGPTeam basedCan link to conventional auditCan be themedPowerful driver for changeLearning can be shared

Root cause analysis

Intensive technique

Usually for most serious incidents (deaths or multiple cases of harm)

Normally at organisational level

Requires trained facilitators

Learning can be shared

Step 6 – Best Practice

Regular structured SEA meetings

Respond quickly when there are important events or when high risks are identified

Involve patients

Learn lessons and put learning into practice – don’t be doomed to see the same event happening over and over again

Step 7 – Implement solutions to prevent harm

Design systems that make it easy for people to do the right thing and difficult for them to do the wrong thing

Solutions that rely on physical barriers are far more effective than those that rely on human behaviour and action

Solutions should be risk assessed, evaluated and sustainable in the long term

Step 7 – Best Practice

Actively consider solutions in SEA meetings

What have others done?

What ideas can we get from staff and patients?

Formal risk assessment of solutions

Share your solutions with others

Where are we now?

Increased awarenessEnlistment of stakeholdersSafety campaigns – 100,000 Lives in USALeadership - ‘Safety First’, Dec 2006Translating to action?What are they actually doing?WHO – Safer SurgeryWhat is happening in New Zealand?

From ‘Seven steps’ to ‘Next steps’

Need safety culture to tackle safety problems, e.g. Infection control needs ALL Seven Steps

Professional understanding and ownership – especially safety culture and human factors

Work with safety professionals – a pilot or an engineer on every Healthcare Board?

Research and evaluation to demonstrate clinical and financial benefits