Patient Safety:

2. Patient Safety: Understanding Human Error in Healthcare

3. Aims • To develop the knowledge, skills and attitudes that promote: • the reduction of medical error to improve patient safety • learning from error in healthcare to improve patient safety

4. Learning Outcomes • Knowledge • What is a medical error? • How and when does this happen? • How do people make errors? • Why do people make errors? • What happens when an error is made? • How do people feel when they make errors?

5. Learning Outcomes • Skills • Recognition of error • Dealing with error • Reporting and learning from error • Supporting others involved in error

6. Learning Outcomes • Attitudes • Focuses on cause rather than culprit • Willing to learn from mistakes • Being prepared to acknowledge and deal with error • Being prepared to reflect on practice • Trust and respect

7. Introduction and Background Human Error- “We cannot change the human condition, but we can change the conditions under which humans work”. (James Reason BMJ March 2000)

8. Personal vs System Approach • Personal approach • focuses on the unsafe acts • “sharp end”- name and shame • System approach • errors seen as consequence not cause • aim to build defences and safeguards • Health care – now learning from other industries • High technology systems have many defensive layers - like a Swiss cheese • Active failures • Latent conditionsReason BMJ March 2000

9. DANGER Some 'holes' due to active failures Defences in depth Other 'holes' due to latent conditions From Reason 1997

10. Definitions • Adverse patient incident - any event or circumstance arising during NHS care that could have or did lead to unintended or unexpected harm, loss or damage. • Harm - injury (physical or psychological), disease, suffering, disability or death. • Incidents that lead to harm- Adverse Events. • Incidents that do not lead to harm - Near Misses. • Other terms which may be used - clinical incident, critical incident, serious untoward event, significant event (National Patient Safety Agency 2001)

11. What is happening? – the world • Australia – Australian Patient Safety Foundation – established as an association 1989 • USA – National Patient Safety Foundation – established 1998 • Canada – Canadian Patient Safety Institute established 2003 • WHO – World Alliance for Patient Safety launched 2004

12. What is happening? - UK • High profile reports of errors leading to patient morbidity and mortality e.g. Bristol • 2000 - Department of Health publish - “An Organisation with a Memory” • 2001 - National Patient Safety Agency established in England • to improve safety of patients by promoting a culture of reporting and learning from patient safety incidents

13. National Patient Safety Agency • The National Reporting and Learning System on patient safety incidents • Aims: • To identify trends and patterns and underlying causes • To develop models of good practice at national level • To improve working practice by feedback and learning • To encourage education and training (NPSA: Seven steps to patient safety, Nov 2003)

14. Discussion • If people try hard enough they will not make any errors • If we punish people when they make errors, they will make fewer of them

15. Extent and Nature of Adverse Events in Healthcare • 850,000 adverse events per year (NHS) • 44,000 incidents fatal • Half are preventable • Accounts for 10% of admissions • Costs the service an estimated £2 billion per year (additional hospital stays alone, not taking into account human or wider economic costs e.g. litigation)

16. Factors Contributing to Human Error • Environmental Factors • Light • Noise and Vibration- Alarms! • Temperature • Humidity • Restrictive/ protective clothing • Equipment layout and design • Physical environment

17. Factors Contributing to Human Error • Some examples of personal factors • Fatigue • Stress • Workload • Distraction • Drugs/ Alcohol • Hypoglycaemia • Hypovolaemia

18. Professional Cultural Issues Underlying Error • A definition of culture • “how we do things around here”

19. Reporting Systems • Some National Examples • Scottish Audit of Surgical Mortality • National Confidential Enquiry into Patient Outcome and Death • Why Mothers Die: Report on Confidential Enquires into Maternal Deaths in the UK • The Confidential Enquiry into Stillbirths and Deaths in Infancy • Yellow Card - BNF • Royal College of Anaesthetists - Critical Incident Reporting • Scottish Confidential Audit of Severe Maternal Morbidity • Some Local examples • OR1 forms / Medication Error reporting forms • Significant Event Analysis in General Practice • Risk management and M&M meetings • Paediatric Surgical error Book

20. Culture - just, reporting, flexible, learning Treats less experienced staff as professionals Accept human fallibility – even good doctors! Training on safety issues Annual appraisal Ground rules established - acceptable and unacceptable behaviour Support / trust / leadership Well run - good input and change implemented with good communication Consistency Clear instructions Anonymity Confidential Voluntary Factors Contributing to Successful Error Reporting

21. Barriers to Successful Reporting • Fear of individual / organisational repercussion • Defining reportable errors too narrowly • Length of contract / time in job • Workload involved - usually time (form filling) • Culture of fear of “losing an otherwise good nurse / doctor” • Where reporting has not brought about change • Uncertainty right and wrong - differing opinions

22. Disclosure • What does it feel like? • What needs to be done? • Write it all down • Document in the patient’s notes • Tell your consultant • Local reporting system • Write to GP? • Tell the defence union • COMMUNICATE! Patient and their relatives

23. Communication • Needs to be handled carefully- all parties in highly charged emotional state • Relatives- distressed / anxious / angry • Health workers- panic / guilt / uncertainty / anxiety • CALM • Enlist help of colleague • Statement of situation and apology • Bad news given - recipients should be offered privacy, access to phones, offers to call family / friend • Organise future meeting from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

24. Meeting with Relatives/ Patients • Ensure all facts are collected and available • If patients have special needs- arrange interpreters • Mutually convenient time • Comfortable environment- no interruptions eg staff / phones / bleeps • Introduce yourself clearly • Establish who is present and why • Explain how the meeting will progress from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

25. Meeting • Explain facts in clear, jargon - free language • Identify unresolved issues and ensure these are being investigated further • Patients current condition and probable outcome should be described honestly • Check on understanding from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

26. Language • Try not to attribute blame unless clear cause • Express regret - “We are extremely sorry that your…” • Avoid comments like “ I can understand how upset you must be” • Rather “In similar circumstances I think most people would feel as you do now, but I can assure you that we want to help you to deal with it” • Person apologising on behalf of the organisation - impartial(?) • Be prepared for a variety of emotional reactions from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

27. Plan • Outline what treatment plan is now being undertaken • Reassure that all possible measures are being taken to resolve harm done • Explain what is being done to prevent same thing happening again • Arrange further meeting if appropriate • Offer a break? • Procedures for compensation • Emotional support • Details about full inquiry • CONCLUSION from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

28. Support Systems • Your colleagues! • Doctors Plus • See patient safety website for details • Sick Doctors Trust • For doctors who are suffering from addiction • www.sick-doctors-trust.co.uk/ • A Framework of Support • GMC • National Counselling Service for Sick Doctors • The British Doctors and Dentists Group • BMA Stress Counselling Service