LESSONSLEARNTB u i l d i n g a S a f e r F o u n d a t i o n

Lead Training 2017

Patient Safety

Lessons Learnt

Lead Preparation

Paul Baker

Key definitions

Policy context

Key theory

Root cause analysis

Patient Safety

Patient Safety

Incident

• ‘The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare’ [Vincent, 2010]

Patient Safety

• ‘Any unintended or unexpected incident that could have or did lead to patient harm’ [NPSA, 2003]

Patient Safety

Incident

2013

BMJ 2001

2001

2001

Examples?

• Prescribing/Preparation

• Administration/ Adverse Drug EventsMedication errors

• Indwelling devices

• Pneumonia/MRSA/C. DiffHospital acquired infection

• SSI

• Wrong site/patient/procedureProcedural adverse events

• Accuracy

• TimingDiagnostic errors

• Missing Record

• InaccuracyDocumentation errors

• Poor Teamwork

• Lack of information flowCommunication errors

Patient NHS Clinician

Patient NHS ClinicianIncreased pain

Disability

Death

Psychological harm

Financial burden:

length of stay

Litigation

Guilt / shame

Job insecurity

2000

• An Organisation with a Memory

2001

• Building a Safer NHS for Patients

• NPSA established

2004• Seven Steps to

Patient Safety

• NRLS established

2008• High Quality

Care for all: NHS Next Stage Review

2013• Francis

Report

1. Patient safety problems exist throughout NHS

2. NHS staff are not to blame

3. Incorrect priorities- finance, targets > care

4. Warning signals abound but not heeded

5. Diffusion of responsibility

6. Improvement requires a system of support

7. Fear is toxic to safety and improvement

NHS should embrace an ethic of learning

Healthcare leaders should place quality and safety as top priority

Patients and carers should be involved

Government, HEE and NHSE should ensure sufficient staff are available

Patient safety and QI should be part of lifelong education of all healthcare staff

NHS should become a learning organisation

Regulatory systems should be simple & clear

Human Error & the Systems Approach

Root Cause Analysis & the London Protocol

Personmodel

Systemmodel

Adverse events are product

of wayward mental

processes: forgetfulness,

inattention, carelessness

Healthworkers are human.

They will make errors.

Adverse events are product

of system ‘pathogens’

Personmodel

Systemmodel

Both extremes have their pitfalls

© J. Reason

Root cause analysis tool

Based on Systems model of error

Full application of Protocol ◦ inspection of records

◦ interviews with staff involved

Key elements used for Lessons Learnt

• What was the outcome?What

happened?

• What were the contributory factors? (Next slide)

Why did it happen?

• What changes should we make, if any?

What can we learn from this ?

Patient factors

◦ Condition (complexity & seriousness)

◦ Language and communication

◦ Personality and social factors

Task factors

◦ Task design and clarity of process

◦ Availability & use of protocols,

◦ Availability & use of test results

Individual staff factors

◦ Knowledge and skills

◦ Motivation, physical and mental health

Team Factors

◦ Verbal and written communication

◦ Supervision and seeking help

◦ Leadership

Work environment

◦ Staffing levels and skill mix

◦ Workload and shift patterns

◦ Design, availability and maintenance

of equipment

Organisation and management

◦ Financial resources & constraints

◦ Organisational structure

◦ Policy standards & goals

◦ Safety culture & priorities

Institutional context

◦ Economic & regulatory context

◦ Social attitudes to risk

◦ National Health Service Executive

◦ Clinical negligence schemes

LESSONSLEARNTB u i l d i n g a S a f e r F o u n d a t i o n

Paul Baker

Global drive to improve

Safety

Growing evidence for

education

Factors impacting delivery

Trainees as ‘Agents for Change’

Understand the principles of quality and safety improvement in healthcare

Discuss safety issues in the framework of case based discussions

Describe opportunities for improving the reliability of care following audit, adverse events or ‘near misses’

Describe root-cause analysis

Demonstrate an understanding of the importance of reporting, discussing and learning from PSIs

Contribute to discussions on improving clinical practice

Perform a quality improvement project and is able to understand the quality improvement process

Other competencies....

Promote structured analysis and learning from PSIs

Improve trainees’ patient safety competencies

Address barriers to sustainable implementation

Methods

Setting

Central team

FPDs 18

FPAs 18

Trainees 1076

Faculty 57

n=1169

60 minute

sessions

Monthly basis

Peer-group

discussion of

PSI

London Protocol

based analysis

Expert-trained

senior doctors

Safe

facilitated

environment

Lessons Learnt

Any unintended or unexpected incident that could

have or did lead to patient harm (NPSA)

Parallel evaluation

Stakeholder engagement

Capacity building

Sustainability key

Jan : Local launches

60 minute

sessions

Monthly basis

Peer-group

discussion of

PSI

London Protocol

based analysis

Expert-trained

senior doctors

Safe

facilitated

environment

Lessons Learnt

Org Change

Behavioural change

Learning

Reaction

81% sites (13/16) held five or more sessions

165 sessions held from January to July 2011

Faculty facilitated 1 to 8 sessions each

n=428

“...The greatest strength of Lessons Learnt is in making changes and improvements from the ground upwards

via the foundation trainees...” FPD

“...I absolutely love these sessions. I learn from them as much as the trainees...” Faculty

“...Lessons Learnt sends a clear message that the blame culture has been laid to rest; that patient safety is more important than naming and shaming...” FY1

• Objective: 51.1% to 57.6% p<0.001

• Self-reported: mean 32% increase

Patient safety knowledge

• Mean 29% increase

Patient safety skills

• Positive baseline attitudes

• Feelings & personal beliefs: no sig shift

• Perceived control: sig improvement

• Behavioural intentions: sig improvement

Patient safety attitudes

n=458-775

n= 428-737

• Novel protocols/ pathways

• Improved accessibility Service Delivery

• Rota re-design

• Nurse staffing ratiosWorking Conditions

• NGT insertion

• Hyperkalaemia managementEducation & Training

• Trainees invited onto Trust Board

• Development of QI groupClinical Leadership

n=32

0 5 10 15 20 25 30

Primary Care

Emergency Medicine

Paediatrics

Obstetrics & Gynaecology

Psychiatry

Surgery

Anaesthetics

Medicine

High satisfaction

• 70% (10-100%) to 80% (40-100%), p < 0.001

Objective knowledge

• Feelings, personal beliefs, perceived control & intentions

Patient safety attitudes

• Root cause analysis & facilitation

Patient safety skills

Sustained in first cohort

Large-scale PS training intervention

Improvement in trainees’ safety competencies

Appetite for senior doctors to engage

Short course efficient & effective

Springboard to quality improvement

Trainee leadership & engagement

Competing interests of faculty

Central vs local administration

Support for quality improvement

Sustained across NW Foundation School

Quality Improvement pilots

Further spread

Multiple awards

Professor Paul Baker

Complete Memorandum of Understanding

Certificate of attendance via email

LL team to send key resources:◦ Today’s slide-pack

◦ Lead Handbook (contains key resources)

Liaise with FPA and local facilitators

Any queries contact liz.morrissey@nw.hee.nhs.uk

• Health Education North West

• All local Foundation teams

Lessons Learnt Team

• NHS North West

• NIHR via the Imperial Patient Safety Translational Research Centre

Funders & sponsors

Ahmed M, Arora S, Hayden J et al. Building a Safer Foundation: The Lessons Learnt Patient Safety Training Programme. BMJ Qual Saf 2014;23:78-86

Ahmed M, Arora S, Baker P et al. Building capacity and capability for patient safety education: A train-the-trainers programme for senior doctors. BMJ Qual Saf 2013;22:618-25

Ahmed M, Arora S, Baker P et al. Case-based learning for Patient Safety: The Lessons Learnt Program for UK Junior Doctors. World J Surg 2012;36:956-8