Transcript Improving Patient Safety on the Wards: Introduction

Improving Patient Safety
on the Wards:
Introduction
Linda Watterson
Programme Manager
Evaluating and
Improving
The size of the problem
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78% EU citizens think medical errors important
problem in their country (Eurobarometer)
44 – 98,000 deaths annually caused by medical error
(To err is human)
Adverse events occur in around 10% of hospital
admissions, or about 85,000 adverse events per
year. (An organisation with a memory)
Spain, France and Denmark have similar figures.
Similar types of intervention related adverse event
happen in all health care systems despite different
organisational and financial systems
The patient perspective
 Patient
evaluation
of care
 Patient
involvement
 Digital Stories
www.patientvoices.org.uk
The nursing contribution
‘nursing
staff can
provide their hospital
with information about
the organisation,
management and
resourcing of care,
that can be used to
improve patients’
experiences’
Views from the sharp end of care
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Blame culture
Feedback
Raising
concerns
Views from the sharp end of care
Competing
priorities
Workload
Staff
deployment
The two words ‘information’ and
‘communication’ are often used
interchangeably, but they signify
quite different things.
Information is giving out;
communication is getting through.
Sydney J.Harris
The 3-bucket model for
assessing risky situations
(Reason, 2005)
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SELF
CONTEXT
TASK
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Human factors
Blunt’ end of care
‘Sharp’ end of care
Decisions made here
Leadership
Institutional context Culture
Communication
Feedback
Targets
Organisation
Priorities
&management of
Equipment
care
Professional development
Working environment Planning
Capacity management
Workload
Staffing
Skill-mix
Health & Safety
Latent failures
(Based on Nolan, 2000; Reason et al 2001)
Impact here
The clinical team
The individual
healthcare worker
The patient
Active failures
Antecedents, determinants and components of safety performance
(Adapted from : Neal & Griffin, 2002)
ANTECEDENTS
Management commitment/leadership
Communication
Rules/procedures/protocols/guidance
Appreciation of risk(s)
Involvement
Safety
Work environment
Climate
Supportive environment
Priority of safety
Personal priorities
Safety climate is one of many
antecedents of safety
performance, for example,
management commitment
and leadership are felt to play
an important role in shaping
workers perceptions of the
safety climate in their
organisation
DETERMINANTS
COMPONENTS
Knowledge & Skill
Motivation
Safety Compliance
Safety Participation
If an individual does not have
sufficient knowledge and skill to
comply with safety regulations or
participate in safety activities, they
will not be able to perform these
actions. If they do not have
sufficient motivation to comply with
safety regulations to participate in
safety activities they will choose
not to carry out these actions.
Compliance and participation represent
behaviours that individuals perform
whilst at work. Safety compliance
describes the core activities that must be
carried out to maintain safety; safety
participation describes behaviours that do
not directly contribute to safety, but which
help to develop an environment that
supports safety.
Management
commitment:
Perceptions of
management’s overt
commitment to
safety
Communication:
The nature and efficiency
of health & safety
communications within
the organisation
Priority of safety:
The relative status of
health & safety
issues with the
organisation
Safety rules &
procedures:
Views on the efficacy
and necessity of
rules &
procedures
Involvement:
The dimensions covered by
the Safety Climate Tool
The extent to which
safety is a focus for
everyone and all
are involved
Personal priorities:
The individuals view of
their own health &
safety management
and the need for feel safe
Work environment:
Personal appreciation
of risk:
How individuals view
the risk associated
with work
Supportive
environment:
The nature of the social
environment at work,
and the support
derived from it
Perceptions of the
Nature of the
Physical
environment
Dimension, Descriptor, Associated Questions
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Dimension:
Perceptions of management’s overt commitment to safety.
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Descriptor:
Management act decisively when a safety concern is raised
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Questions:
- Management acts only after accidents have occurred
- Corrective action is always taken when management is told about
unsafe practices
- In my workplace management acts quickly to correct safety problems
- In my workplace management turn a blind eye to safety issues
- In my workplace managers/supervisors show interest in my safety
- Managers/supervisors express concern if safety procedures are not
adhered to
REASON, 2005
Strengthening the nursing
contribution
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Reporting and learning
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Value of reporting
Valuing the nurses understanding of safety issues
Developing positive cultures
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Blame culture
Empowerment
Training opportunities
Improving communication
Work environment
Staffing level /skill mix /workload issues
Use audit and benchmarking
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Sharing solutions
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Valuing the nurses role
Sharing best practice
Tools and techniques
Patient / consumer involvement
Proposed approach
 Focus
for patient safety
 Support
and strengthen the value of the
nursing voice
 Provide members with appropriate tools to
review safety at all levels
 Provide learning and development resources
and opportunities
 Consider the value of the patient voice for
learning and challenging
Sharing best practice
Contact: [email protected]
References and useful reading
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Anderson DJ. Webster CS (2001) A systems approach to reduction of medication error on the hospital ward
Journal of Advanced Nursing 35 (1) 34 – 41
Attree M (2007) Factors influencing nurses’ decision to raise concerns about care quality Journal of Nursing
Management 15 392 - 402
Currie L, Watterson L, (2007) Challenges in delivering safe patient care. A commentary on a quality improvement
initiative Journal of Nursing Management 15 (2) 162 - 168
Department of Health Expert Group An organisation with a memory: report of an expert group on learning form
adverse events in NHS Chairman :Chief Medical Officer London: The Stationery Office 2000
http://ec.europa.eu/health/ph_information/documents/eb_64_en.pdf
King L Macleod Clark J. (2002) Intuition and the development of expertise in surgical ward and intensive care
nurses Journal of Advanced Nursing 37 (4) 322 – 329
Kohn LT Corrigan JM Donaldson MS eds To err is human: Building a safer health system. Washington, D.C.
National Academy Press 2000
http://www.saferhealthcare.org.uk/ihi
Mrayyan MT, Huber DL (2003) The Nurses Role in Changing Health Policy Related to Patient Safety JONA’s
Healthcare Law, Ethics and Regulation 5 91
Meurier CE (2000) Understanding the nature of errors in nursing: using a model to analyse critical incident
reports of errors which had resulted in an adverse or potentially adverse event Journal of Advanced Nursing31
(1) 202 - 207
Sorlie V, Torjuul K, Ross A, Kihlgren M (2006) Satisfied patients are also vulnerable patients – narratives from an
acute care ward Journal of Clinical Nursing 15, 1240 – 1246
Storr J TopleyK, Privett S. (2005) The ward nurses role in infection control Nursing Standard 19 (41) 56 – 64
Sdottir H A, Bjornsdottir K (2008) Nursing and patient safety in the operating room Journal of Advanced Nursing
61 (1) 29 - 37
Walker AC, (2002) Safety and comfort work of nurses glimpsed through patient narratives Internationaol Journal
of Nursing Practice 8: 42 – 48
West E, Barron DN, Reeves R (2005) Overcoming the barriers to patient – centred care: time, tools and training
Journal of Clinical Nursing 14, 435 – 443
www.npsa.nhs.uk
www.who.int/patientsafety
Key action areas for ward nurses in preventing infection
Ref: Storr J. et al The nurses role in infection control Nursing Standard 19 (41) 22 June 2005