Transcript Slide 1

Learning from Adverse Incidents
Hazel Baird
Head of Governance & Patient Safety
Northern HSC Trust
To err is human ………..
Institute of Medicine 2000
Approximately 1 in 10 patients experience avoidable
Harm or suffering due to mistakes in hospitals
Do we think?
• If a professional is highly trained and tries hard
enough he/she will not make mistakes
• Errors and mistakes equate with personal failure and
incompetence
The perfection myth
If we try hard enough we will not make mistakes
The punishment myth
If we punish people when they make mistakes they
will make fewer of them
In reality ……
95% of errors that cause harm involve conscientious
competent individuals trying hard to achieve the best
outcome for those in their care
Only 5% of harm is caused by incompetence or poorly
intended care
“The organising principle is that the cause (of
preventable harm) is not bad people but bad
systems”
Lucian L Leape
Clinica.chinica acta. Vol 404 June 2009
Leape further suggests that in our
healthcare systems:
• The focus should be on systems not individuals when
errors occur
• There should be greater transparency and less secrecy
• Care should be patient centred and
• There should be a greater dependence on teamwork
not individual performance
• Patients (carers) should be more fully engaged in their
care
Open and fair culture
Staff must feel safe to report incidents and
safety issues
To achieve this, the incident investigation
must be
• Fair and equitable
• Focused on learning and change
• Focused on identifying contributory and root causes
RCA example of 5 whys?
• Nurse didn’t complete obs sheet
• There were 3 obs sheets
she completes one
• Pilot new obs sheet 2 years ago
original obs sheet
one for post-surgery
• Obs policy working group
hadn’t met for 6 months
• Work pressures and obs policy wasn’t priority
• Development of obs policy not written
into anyone’s objectives
why?
why?
why?
why?
why?
The basic premise of the systems approach to
reducing error is that humans are fallible
and errors are to be expected
“Therefore measures to reduce errors need
to build defences within the systems in
which humans work”
James Reason
Human Error-Models&Management
Case History
• Mrs Brown 88 years admitted to hospital from pnh with history
of pyrexia, vomiting and falls
• Past history of stroke, chf and ischaemic heart disease poor
short term memory
• Rx i.v. antibiotics and i.v. fluids
• 4 days later at 4am found face down on floor at side of bed.
floor wet urine sustained head injury that led to her death 3
weeks later
• 1 month later Mrs Green admitted to another hospital in the
trust. Sustained a fall and died from head injury
Investigation Methodology
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•
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•
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A time line was created
Notes examined
Problem identification – questions to be addressed
Staff interviewed
Policy position explored
Falls and bed rail literature reviewed
Questions to address
• Was Mrs Brown’s risk of falling recognised, managed and
communicated between wards?
• Was professional record keeping of an acceptable standard?
• Were Mrs Brown’s needs appropriately communicated between
wards?
• Did movement between wards adversely affect Mrs Brown’s
care?
• What is the trust’s policy position on the assessment and
management of patients at risk of falls?
• How does the trust’s falls rate benchmark against other
hospitals?
• What resources are available to staff to try to prevent falls in
hospitals or reduce injury from falls?
Date
Time
Ward
Duration
in Ward
Reason for moving
Notes
2/10/07
00:40 hrs
A
Admission
Unit
17 hours
Patients are moved
from Admission Unit
usually within 24hours
Multi-disciplinary
progress notes
2/10/07
17:40 hrs
B
25 ½ hours
Medical request for
telemetry on Cardiac
Ward
Multi-disciplinary
progress notes
3/10/07
19:15 hrs
C
26 hours
Needed the Cardiac
bed
Nursing progress
notes
4/10/07
21:00 hrs
D
31 hours
After 31 hours, Mrs B
sustained a fall with
serious injury
Multi-disciplinary
progress notes
Recommendations
• Patient movement between wards needs to be
reviewed, this is particularly important for elderly,
confused patients. Clinicians should be asked to
consider the merits of moving an elderly patient for
telemetry, versus the overall care issues it creates for
them.
• Transfer checklists are a useful tool to ensure
essential information is communicated between
wards, but a field for ‘risk of falling – special measures
needed’ should be considered. All forms should be
signed.
Recommendations, contd..
• Recording formats for patient notes should ideally be
standardised, so that there is clear continuity of
recording between wards and across the Trust.
Problems experienced by the review team may also
have been experienced by ward staff.
• The use of multi-professional progress notes and care
planning documentation needs to be reviewed and if
they continue to be used, there should be explicit
guidance and standards developed for their use.
Recommendations, contd..
• A simple audit of standards for professional recordkeeping should be implemented six to twelvemonthly, as resources permit.
• A Trust-wide policy on prevention of falls in hospital
and the safe use of bed rails should be developed.
These policies will address risk assessment and care
planning and will need robust implementation plans.
Recommendations, contd..
• The risk management department and service should
discuss improvements in recording outcomes from
falls.
• The Trust should discuss with DHSSPS colleagues the
benefits of regional benchmarking and possibly
national benchmarking through NRLS.
To maximise learning; you need
• A good investigation team
• A well structured report
• Clear conclusions and recommendations with
associated action plan
• The report and ‘learning’ shared in department,
directorates, organisation other organisations in a
constructive way
• To evidence the delivery of the action plan
and
• Audit compliance issues to provide assurance
“ The names of the patients whose lives we save can
never be known. Our contribution will be what did not
happen to them. And, though they are unknown, we
will know that mothers and fathers are at graduations
and weddings they would have missed, and that
grandchildren will know grandparents they might
never have known, and holidays will be taken and
work completed, and books read, and symphonies
heard, and gardens tended that, without our work,
would have been only beds of weeds”
Donald Berwick, President of the Institute for Healthcare Improvement