Transcript LEARNING FROM INCIDENTS - Patient Safety Federation

LEARNING FROM INCIDENTS
Dr Bill Kirkup
CONTENT
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Straightforward pathway
Incidents and recognition
Reporting and analysis
Implementing improvement
Major incidents
Critical points and principles
FROM INCIDENT TO LEARNING
Incident
Recognition
Errors,
slips, lapses
Price for complex skills
Analysis
Reporting
Often
dependsand
on admission
Systems factors predominate
Socialisation and role models
Learning
But also
competence/conduct
What
and why (root cause)
Institutional response
Identify prevention
Denial
(including
self)
System
design
improvement
Improving knowledge of risk
Implement local change
Spotting trends
Communicating findings
Enable wider change
INCIDENTS AND RECOGNITION
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Ingrowing toenail 38 weeks pregnancy
Sepsis; OP appointment 6 months
SHO offered removal with local anaesthetic
Plain lignocaine required for ring block
Checked ampoule, drew up lignocaine
Rechecked ampoule
With adrenaline...
POTENTIAL LESSONS
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Wrong setting: antenatal clinic
Other staff unfamiliar with procedure
Poor labelling, especially glass ampoules
Anticipation affects perception
Seeing
what you
you expect
SYSTEMS FAILURES
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Ladbroke Grove rail crash 1999
Head on collision, high combined speed
‘Signal passed at danger’ (SPAD)
8 previous SPADs in 6 years at location
Site and design of signal
Ineffective points interlocking
Inadequate driver training
Lack of route experience
LONGSTANDING FEATURE
Those entering hospital…
…were exposed
to more chances
of death than
was the English
soldier on the
field of Waterloo
JY Simpson
Donald Robertson 1785-1848
His death was much regretted which was caused by the
stupidity of Laurence Tulloch in Clothister (Sullom) who
sold him nitre instead of Epsom salts by which he was
killed in the space of 5 hours after taking a dose of it.
Gravestone inscription, Shetland Isles
WORLDWIDE RESEARCH
• 10% of hospital admissions
result in an adverse event
• 8% contribute to fatal outcome
• 6% cause serious impairment
• 50% of incidents are avoidable
CONSEQUENCES
• 16 patients suffer injury or harm
each day
• 11 avoidable deaths occur each
day
• Patient safety incidents cost
£3billion each year
HOW RISKY IS HEALTHCARE?
Less than one death per 100,000 episodes
•Nuclear power
•European railways
•Scheduled airlines
One death per 1,000 - 100,000 episodes
•Driving in UK
•Chemical manufacturing
More than one death per 1,000 episodes
•Bungee jumping
•Mountain climbing
•Healthcare
INCIDENT REPORTING
350,000
NPSA Figures for England
300,000
250,000
200,000
150,000
100,000
50,000
0
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2003 2004 2004 2004 2004 2005 2005 2005 2005 2006 2006 2006 2006 2007 2007 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010
DEGREE OF HARM REPORTED
Moderate
5.7%
Severe
0.5%
Death
0.2%
Low
22.1%
No Harm
71.6%
REPORTED AGAINST EXPECTED
Expected from
cumulative research
Observed, NPSA 2010
(Acute Sector)
Severe/
Death
14%
Severe/
Death
2.3%
Not
Severe
86%
Not
Severe
97.7%
CRITICAL POINT 1: BLAME
• 90% not individual factors
• Pressure for scapegoat
– victims, public, media
• Systems seem nebulous
– ‘who is accountable?’
• Blame is ‘emotionally
more satisfying’ (Reason)
• Counter to developing
open reporting and
learning culture
• ‘Encouraging the others’ is
ineffective
LEARNING: IMPROVING SYSTEMS
Wayne Jowett
• 18 years old, an apprentice mechanic
• In remission from leukaemia
• Anti-cancer drug injected into spine instead of
vein
• Died one month later
• 48 failures of procedure traced
A SYSTEM SOLUTION?
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Universal use of Luer lock connections
Wide range of misconnections possible
Design and introduce non-Luer system
Programme commenced 2002
Design, correction, piloting until 2009
Further problems evident
31/1/2011 PSA: April 2012
IMPLEMENTING SYSTEM SOLUTIONS
November 2000
Death of 3-year-old girl, Newham
May 2001
Notice on machine safety issued
October 2001
July 2002
Compliance reports from CEs
186/5657 non-compliant, 139 in use
November 2002
All machines reported compliant
2003
Survey: 25 Trusts non-compliant
January 2005
Final notice issued
ORAL METHOTREXATE
Compliance with Alert issued July 2004
100
90
Deadline 245 Days
80
% Compliant
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20
10
0
80
100
120
140
160
180
200
Days since Alert
220
240
260
280
Source: CMO Annual Report, 2004
ORAL METHOTREXATE ALERT
Compliance at 300 days by SHA
Greater Manchester
W Yorkshire
SW Peninsula
Norfolk Suffolk & Cambs
Dorset & Somerset
Shropshire & Staffs
Thames Valley
S Yorkshire
Cumbria & Lancs
Co Durham & Tees V
Trent
Avon Gloucs & Wilts
Hampshire & IOW
Surrey & Sussex
SW London
Nthmbld Tyne & Wear
Kent & Medway
Cheshire & Mersey
NW London
B'ham & Black Country
N Central London
Leics Northants & Rutld
West Midlands
Bedfordshire & Herts
SE London
Essex
NE Yorks & Lincs
NE London
% Compliant 0
20
40
60
80
100
Source: CMO Annual Report, 2004
NPSA 2006/07
• 18% NHS organisations still not
compliant after two years
• 14 incidents led to 2004 alert
• Since alert, 151 further incidents
• Progress since?
THE ORANGE WIRE TEST
The Lancet 2004; 365: 1567-1568
CRITICAL POINT 2: LEARNING
• “It could never happen
here”
• “The solution won’t work
here”
• “We have more pressing
priorities”
• The Streeb-Greebling
Effect:
“Have you learned from your
mistakes, Sir Arthur?”
“Yes I have, and I could
repeat them all perfectly”
MAJOR INCIDENTS
MRS MAVIS SKEET
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Age 73, Wakefield, oesophageal cancer 1999
Good response from radiotherapy May 1999
Further difficulty swallowing September 1999
Endoscopy October 1999 showed recurrence
Surgery planned Leeds General Infirmary
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6/12/99: cancelled, anaesthetist unwell
20/12/99: cancelled, no ICU bed
27-29/12/99: no ICU bed available
10/1/00: cancelled, no ICU bed
11/1/00: endoscopy – trachea fixed
Repeat radiotherapy (palliative)
“Dear Mr Blair”
“I write to you today to ask why I must suffer the agony
of watching my mother slowly die” (Daughter)
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“Cancer inoperable after flu delay” (BBC)
“Cancer sufferer doomed by flu delay” (Guardian)
“The NHS is not working…” (Observer)
“National outrage…” (Mail)
“NHS in crisis” (Mirror)
“… she had a right to live but she won’t” (S Mirror)
“In Britain’s Health Service, sick itself, cancer care
is dismal” (New York Times)
“The Health Secretary, Alan Milburn, has ordered an inquiry into a
hospital's treatment of a cancer patient after surgery cancelled four
times has left the cancer inoperable” (Independent)
REPORT ON TREATMENT AND CARE
of Mrs Mavis Skeet by Leeds Teaching Hospitals NHS Trust February 2000
• Initial expectation: ‘name, shame and blame’
• Clear evidence from occupancy patterns:
– all 40 ICU beds across Leeds consistently full
– patients being ventilated in recovery areas
– emergency transfers declined several times
• Review confirmed decisions and their basis
• “A serious deficiency in quality of NHS care”
• Root cause: increased specialist transfers; capacity
• “A further increase in critical care facilities… a
priority to minimise the risk of recurrence”
SUBSEQUENT EVENTS
• Immediate additional 450 ICU beds funded
• Regional bed bureaus to co-ordinate capacity
• But also:
– ‘Breakfast with Frost’ pledge on NHS funding
– reversal of previous hospital bed policy
“When it comes to writing the first draft
of political history, the name of Mavis
Skeet will probably not even merit a
footnote” (Guardian, 2002)
“It is hard now to look back and realise
just how inevitable such crises appeared”
(Blair, T: A Journey 2010 p261)
Mrs Skeet died June 2000
“AN APPALLING INCIDENT”
MIDDLESBROUGH GENERAL HOSPITAL
• Patient A, aged 60+, admitted to MGH 2002
– cognitive impairment including memory loss
– no ataxia, no myoclonus, stable over 8 months
– probable cerebral vasculitis or dementia
– brain biopsy July 2002 to exclude vasculitis
• Histology: no vasculitis seen, further tests
• Later some vacuoles seen, sent to Edinburgh
• 8 August 2002: CJD identified in sample
• CJD Incidents Panel contacted
– 34 patients potentially at risk
– panel meeting due 17 October 2002
– instruments quarantined
‘THE GUARDIAN’ STEPS IN
• CJD Incidents Panel Meeting 17 October:
– brain biopsy to confirm clinical picture of CJD?
– critical of instrument decontamination
procedures
– considered 29 patients at risk, to be contacted
– draft letter awaiting signature 11 days later
• Leaked information with The Guardian
• Story went live 29 October 2002
DH Media team statement:
“The guidance issued to the NHS in August 1999 is crystal clear. Instruments used
on any suspected cases of CJD must be quarantined immediately after use pending
confirmation of the diagnosis. All NHS Trusts should adhere to this guidance to
prevent avoidable and unnecessary exposure to these diseases. In this case it
appears that the Trust concerned failed to do so and as a result we need to check
what patients have been put at risk. Described as an appalling incident.”
PRESS COVERAGE PREDICTABLE
• Extensive national media coverage
• “Hospital blunder…fatal brain disease” (All)
• “Appalling incident…failures” (Most)
• “The Department of Health last night
confirmed ‘an appalling incident’ had taken
place…in which the hospital had failed to
prevent avoidable exposure…” (Guardian)
• “Row over hospital blunder” (Most)
This is how 29 people who had potentially been
exposed to CJD found out. So did 150+ who had
neurosurgery at that time but who had not been
exposed to transmission.
REPORT OF INCIDENT REVIEW
• Did the Trust follow the right
quarantine procedure?
• Is manual instrument
decontamination acceptable?
• Should there be a tracing system
for surgical instruments?
• Was the CJD Incidents Panel
advice helpful and timely?
• Was DH media line wellinformed?
• Was the Trust’s handling right?
RECOMMENDATIONS AND OUTCOME
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Quarantine (non-focal) brain biopsy instruments
Reform operation of CJD Incidents Panel
Clarify guidance on manual decontamination
Make instrument tracking mandatory
Improve DH Comms Department’s local liaison
Commend NHS staff
INDIVIDUALS AND SYSTEMS
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1970: O&G training; Canada 1977
1979: lost privileges BC, postop death
1981: investigation Ontario, maternal death
1984: appointed consultant Northallerton
1985: erased Canadian medical register
1989: ‘woeful and inadequate’ investigation
1991: Richmond public toilet incident
1993: ‘overly positive’ investigation
1995: on-call problems; left Trust
1996: assaulted porter, Leicester
1999: patient complaints emerged
2000: GMC erased UK register
SYSTEMS FAILURES
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Lack of pattern recognition
Poor communication
Misuse of references
Reliance on colleagues
Constraints of consultant terms
CRITICAL POINT 3: PATTERNS
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Pattern recognition usually good
If anything, usually too prone to find
But requires information to examine
Incidents considered in isolation
Incidents considered without context
Information may not be shared
– across borders
– between systems
– between organisations
CONCLUSION: SOME PRINCIPLES?
“These are my principles. If you don’t like them, I have others.”
CONTEXT
“The UK’s problems in providing safe care are
shared by most developed countries. But the UK
led the world in confronting the issues….”
Kennedy: Learning from Bristol: Are we?
As a result, the NHS now has:
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extensive clinical governance systems
national reporting and learning
unprecedented rates of reporting
72 current patient safety alerts
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CRITICAL POINT 1: BLAME
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Powerful disincentive (whatever source)
Suppresses most reporting
But encourages trivial reports
Blanket disciplinary edicts unhelpful
RCAs not part of disciplinary process
‘Encouraging the others’
remains ineffective
CRITICAL POINT 2: LEARNING
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Most root causes are reproducible
‘It could happen here’
Solutions can be invented elsewhere
Is patient safety a priority?
Engagement, commitment, leadership
Or risk repeating our
mistakes perfectly
CRITICAL POINT 3: PATTERNS
Look at previous history
Share information (eg references)
Incidents don’t happen in isolation
Monitoring and audit
Statistical techniques can help
45%
Successful outcome (%)
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Successful Outcome
As percent of treatments
40%
35%
30%
25%
20%
15%
10%
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1000
1500
2000
Number of Treatments
2500
3000
FINAL COMMENT
Events beat strategy
every time