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 Londonwww.cpssq.org

OverviewUnderstanding patient safetyWhat 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 healthcareNegative or positiveReactive or proactiveAn Aspiration & AmbitionOne of a number of objectivesThe heart of quality

Consequences of serious adverse events for patients & familiesDeath of neonates, children, adultsLoss of womb in young womenUntreated cancer, mastectomyBlindnessDisability and handicap, children and adultsChronic pain, scarring, incontinenceProfound effects on all aspects of their livesVincent, 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

Epidemiology of harm

StudyDate of admissionsNumber of hospital admissionsAdverse event rate (% admissions)California Insurance Study1974208644.65 *Harvard Medical Practice Study 1984301953.7Utah-Colorado1992140522.9Australian 19921417916.6United Kingdom1999101410.8Denmark199810979.0New Zealand1998657911.2France **200277814.5Canada200037457.5

The unreliability of healthcareUndre et al, 2006

Chart2

2872

4258

3862

7228

NO

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% Checked

Surgical Equipment Checks

Sheet1

NOYES

Anaes Equip2080

Anaes Logbook3763

Anaes Logbook uptodate7228

NOYES

Surg Instruments2872

op specific equip4258

diathermy3862

suction7228

Sheet1

00

00

00

NO

YES

% Checked

Anaes Equipment

Sheet2

00

00

00

00

NO

YES

% Checked

Surg Equip

Sheet3

00

00

00

NO

YES

% Checked

Anaes Equip

00

00

00

NO

YES

% Checked

Anaes Equip

00

00

00

00

NO

YES

% Checked

Surg Equip

Understanding why things go wrong

The safety paradoxHealthcare staff are:Highly trained & motivatedCommitted to their patientsUse sophisticated technologyErrors are common and patients are frequently harmed

Understanding why things go wrongChain of eventsComplexity and contributory factorsThe importance of cumulative minor errors and deviationsTackling safety on many levels

Contributory factors: 7 levels of safetyPatientTaskIndividual staffTeamWorking conditionsOrganisationalGovernment and regulatoryVincent, 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 questionsPronovost et al, 2003

The Impact of Daily GoalsStructured and organised care for each patientReliability reducing the gap between what should be happening and what is actually happeningReduced length of stay from 2.5 to 1.3 daysPronovost, 2003

Catchpole et al, 2007II Patient handover

Process Organisation

Task sequenceA rhythm and order to eventsTask allocationTeam members have defined tasksLeadershipWho 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 StopHandoverCatchpole et al, 2007

Performance improvements with new handover protocolObservation 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 monthsMean rate at baseline decreased from 7.7 to 1.4 at 16-18 months follow up

Care bundles & organisational changeA focus on systems Local ownership and engagement Encouraging local adaptation of the intervention Creating a collaborative cultureTime and resourcesPronovost et al, 2008

So what should we try to communicate?

Becoming awareCommunication in Emergency CareTracking the process `I just could not believe we were doing all thisObserving the handover `Staggering, jaw droppingPutting on my `second hat (Krishna Moorthy)

The essentials of patient safetyThe human tragediesScale of error and harmThe safety paradoxReflecting on ones own environmentThe informal nature of many healthcare processesThe many levels of influence and interventionThe potential for simple changesThat they can make a difference

Safety in clinical practice II 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 IIBeing 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.ukCentre for Patient Safety & Service Qualitywww.cpssq.org Further Information

Stress a few things about the value of case analysis, sometimes lost when you have to do it because its demanded of you, or when its done in a top heavy way, bureaucratic way.

Analyses bring rich detail on evolution of incidents and contributory factorsGreatest potential in close analysis of small numbersEnsure comprehensive approach without `premature closure

To me its a structured way of reflecting on the system in which you work. What youre doing is not looking back to what happened, at least only in part. Really, youre looking to the future. Whats this case tell us about our system. A route to the broader system and to interventions

Two really important uses:

1. To bring the systems view to life. People often say, how to persuade people. I think this is a great way for a team to think about.

2. To identify the persistent themes and consider priorities for interventions, at whichever level they seem to be showing.

However, while I think this is a great help, I dont think we should rely on analysis of incidents etc entirely for improving safety. . And this is subject of Part II.

PART II ...

Stress a few things about the value of case analysis, sometimes lost when you have to do it because its demanded of you, or when its done in a top heavy way, bureaucratic way.

Analyses bring rich detail on evolution of incidents and contributory factorsGreatest potential in close analysis of small numbersEnsure comprehensive approach without `premature closure

To me its a structured way of reflecting on the system in which you work. What youre doing is not looking back to what happened, at least only in part. Really, youre looking to the future. Whats this case tell us about our system. A route to the broader system and to interventions

Two really important uses:

1. To bring the systems view to life. People often say, how to persuade people. I think this is a great way for a team to think about.

2. To identify the persistent themes and consider priorities for interventions, at whichever level they seem to be showing.

However, while I think this is a great help, I dont think we should rely on analysis of incidents etc entirely for improving safety. . And this is subject of Part II.

PART II ...

*We felt we could improve on this process, not least because our own studies had shown that this is a critical time for the patient and one near miss had been related to poor transfer of information.

We realised that there was a comparison to be made with a Formula 1 pit stop, which also has:Multiple specialistsComplex tasksComplex team and equipment interfacesTime pressureNeed for accuracy*Overall, this new process reduced: the number of equipment errors,the number of information omissionsAnd the duration of the process.