Key issues for the next decade:

Assessing Safety

The Measurement and Monitoring of Safety in Healthcare

Susan Burnett Centre for Patient Safety and Service Quality,

Imperial College London

Copyright ©2008 BMJ Publishing Group Ltd.

Fig 2 Changes in rates of 9 AHRQ derived patient safety indicators. Hospital Episode Statistics 1996-7 to 2005-6, England

Vincent, C. et al. BMJ 2008;337:a2426

Is Healthcare Getting Safer? Vincent, C. et al.

BMJ 2008;337:a2426

Charles Vincent

Susan Burnett

Jane Carthey

Methods

1. Reviews of research literature and reports from organisations:

Safety relevant industries

Conceptual approaches and models of systems safety

Measurement and monitoring in healthcare

The role of patients and families

2. Interviews with senior staff in national organisations

3. Case studies in healthcare organisations in the UK and USA

Acute & specialist trusts Mental Health Primary care Combined organisations Clinical services: maternity care, care of the elderly,

anaesthesia

Five key questions:

1. Has patient care been safe in the past?

2. Are our clinical systems and processes reliable?

3. Is care safe today?

4. Will care be safe in the future?

5. Are we responding and improving?

Has care been safe in the past?

• General harm from healthcare (e.g. HCAI)

• Treatment-specific harm (complications)

• Overtreatment (falls – sedatives)

• Delayed or inadequate diagnosis

• Failure of appropriate treatment

• Harm from error

• Psychological harm and feeling unsafe

Many different categories of harm:-

And there are many different measures of harm:-

• Mortality statistics

• Record review

• Global Trigger Tool

• Staff reporting

• Routine databases

Each gives a partial assessment of the underlying broad issue of harm

“Without the letter, the patient's perception of why they're in clinic may be different to the reasons that the GP stated or there may be pertinent facts which the patient doesn't describe....”

in

Overall results: missing clinical information

‘We always need a

colposcope with that list

and time and time again it

isn’t there or it’s broken or

it isn’t back or nobody

knows where it is’

Surgeon 3 Organisation A

‘We always need a colposcope with that list and

time and time again it isn’t there or it’s broken or it

isn’t back or nobody knows where it is’

Surgeon 3 Organisation A

Overall Results

in

Sensitivity to Operations: Is care safe today?

What might change safety today? • Staffing levels • Volume of patients • Patient dependency/acuity on the wards

Examples • Routine monitoring in Anaesthesia • Safety Walkrounds • Briefings and Checklists • Safety Huddles and Handovers • Patient interviews

Anticipation and Preparedness: Will care be safe in the future?

Examples: • Safety in surgery

• Falls risk assessments

• Pressure ulcer risk assessments

• Risk registers

• FMEA

• Safety culture assessments

• Safety cases

Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics

Paul Aylin et al, BMJ 2013;346:f2424 (Published 28 May 2013)

Results There were 27 582 deaths within 30 days after 4 133 346 inpatient admissions for elective operating room procedures (overall crude mortality rate 6.7 per 1000). The number of weekday and weekend procedures decreased over the three years (by 4.5%

and 26.8%, respectively). The adjusted odds of death were 44% and 82% higher, respectively, if the procedures were carried out on Friday (odds ratio 1.44, 95% confidence interval 1.39 to 1.50) or a weekend (1.82, 1.71 to 1.94) compared with Monday.

Hospital Nurse Staffing and Quality of Care Research in Action, Issue 14 (2004)

Hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes such as pneumonia, shock, cardiac arrest, and urinary tract infections, according to research funded by the Agency for Healthcare Research and Quality (AHRQ) and others.

http://www.ahrq.gov/research/findings/factsheets/services/nursestaffing/index.html

The Working Hours Of Hospital Staff Nurses And Patient Safety

Both errors and near errors are more likely to occur when hospital staff nurses work twelve or more hours at a stretch.

Ann E. Rogers, Wei-Ting Hwang, Linda D. Scott, Linda H. Aiken, and David F. Dinges

DOI 10.1377/hlthaff.23.4.202 ©2004 Project HOPE–The People-to-People Health Foundation, Inc.

Are we responding and improving?

• Integrating safety information across the organisation

• Providing information at the level for interpretation and action

• Building learning into organisational development – not just a clinical issue

Key Issues

1. Developing ways to anticipate and be proactive

2. Safety monitoring should receive more attention

3. Safety information is fragmented in healthcare organisations – integration and learning needs investment in technology and data analysis

4. Safety information needs to be customised to the different levels

5. Improving safety is an organisational development issue, not just a clinical issue

CPSSQ: http://www1.imperial.ac.uk/medicine/about/institutes/patientsafetyservicequality/

The report: http://www.health.org.uk/publications/the-measurement-and-monitoring-of-safety/