Transcript Risk Management in General Practice

Learning from incidents
Keith Reynolds
Risk Manager
South Warwickshire General Hospitals NHS Trust
Incident
Unplanned event which resulted or had
the potential to result in injury, loss or
damage
Incident example
In 1998 the patient attended A+E having
been stung by a wasp. Anaphylactic
shock resulted and she was admitted to
hospital for 6 days. One particular
symptom was a period of blindness.
Drugs prescribed include IV adrenaline,
piriton, maxalon, and cyclizine.
Allegations
A 1mg dose of adrenaline was given in
one shot IV leading to a nonhaemorrhaging infarct in the brain
causing ischaemia affecting eyesight
and causing amnesia amongst other
symptoms. Claimant no longer able to
work.
Cost
This case estimated at £480,000
 Total cases involving the Trust £10
million
 Total cases settled last year in the NHS
£250 million

Incident Investigation
“Rather than being the main instigators of
an accident, operators tend to be the
inheritors of latent failures created at
the blunt end. Their part is usually that
of adding the final garnish to a brew
which has been long in the cooking.”
Reason: Human Reliability (1988)
Risk management and
corporate governance
Clinical Assurances
(Clinical Governance
Report/Annual Report)
Clinical care
The
environment of
care
Financial
resources
CLINICAL
GOVERNANCE
ORGANISATIONAL
CONTROLS
FINANCIAL CONTROLS
Organisational
Assurances
(Annual Report)
Financial
Assurances
(Annual Accounts)
National Health Service
initiatives
AS/NZS 4360:1999, Risk Management
 Clinical governance
 Controls assurance
 Clinical Negligence Scheme for Trusts

– risk pool
– risk management standards with discounts
CLINICAL NEGLIGENCE SCHEME FOR
TRUSTS - RISK STANDARDS







Clinical RM strategy
Defined Board
responsibility
Clinical RM
Incident reporting
system
Rapid follow-up of
major incidents
Complaints
management
Patient information on
risks and benefits





Standards for medical
record keeping
Induction arrangements
for clinical staff
Clinical risk
management system
Clinical care guidelines,
accountability etc
Maternity care
standards for high risk
pregnancy
RM STANDARDS (cont.)
Standards for medical record keeping
 Induction
 Clinical risk management system
 Clinical care - guidelines, accountability
etc
 Maternity care

Controls Assurance
standards







Risk mgt. system
Buildings, land,plant and
non-medical equipment
Catering and food hygiene
Contracts & control of
contractors
Emergency preparedness
Environmental management
Fire safety












Health and safety mgt.
Human resources
Infection control
IM&T
Medical devices mgt.
Medicines management
Professional and product
liability
Records management
Security
Transport
Waste management
Decontamination
Corporate Governance
May 2000
Management
assurance
Independent
assurance
Trust Board
Clinical
Governance
Committee
Specialist clinical
governance committees
Research and ethics
committee
Drug and therapeutics
committee
Practices and procedures
committee
Audit and Risk
Group
Directorate
Corporate
Governance
committees
Specialist
Directorate
committees
TMT
Controls
Assurance
Committee
Specialist controls
assurance committees
Health and Safety committee
Security group
Waste group
Infection control committee
Medical records group
CIPB
Finance and audit
committee
Internal audit
Everyone makes mistakes…..
Clinical litigation costs in UK
6000
5000
4000
£ millions 3000
2000
1000
0
1975 1980 1985 1990 1996 2001
Year
Claims against the NHS
Current claims against the NHS cost/£billions
Obstetrics
Others
2
4
Current claims against the NHS number
8,300
16,660
Source: NHS Litigation Authority
Obstetric claims against the
NHS
2000
1800
1600
1400
1200
1000
800
600
400
200
U
th
er
O
nn
's
ar
y
pa
in
ag
e
da
m
Br
ai
n
pa
ls
y
Er
bs
lit
y
Fa
ta
Ce
re
br
al
pa
ls
y
0
No.
Cost/£millions
Cost/
£millions
5
4
3
2
1
0
dent
gastro
urol
itu
haem
ophth
anaes
vasc
oncol
gyn
paed
ent
med
a/e
orth
surg
7
6
midwif
obs
Even locally…….
Clinical litigation by speciality
SWGH 1990-1999
Speciality
anaes
haem
itu
radio
dent
gastro
vasc
urol
oncol
ophth
paed
ent
gyn
med
midwif
orth
surg
25
20
15
10
5
0
obs
Clinical litigation cases by speciality
SWGH 1990-1999
a/e
No.
Even locally…...
At every level……..
Occupation
therap
lsho
sreg
sfgd
lcon
sister
stnur
midw
reg
sho
80
60
No. 40
20
0
con
Clinical litigation claims by occupation
SWGH 1990-1999
No.
0
Other
Competence
foreign body
Wrong site
Medication
Adm delay
a-natal
abnormality
Follow-up
Consent
Fetal Heart
rate
Supervision
Damage
Diagnosis
Why did it happen…...
35
30
25
20
15
10
5
Costs of clinical incidents
Inj
dis ury,
ea
dea se,
ible
litig th, Tang s
atio
se
n
los
Inc
rea
se
l
e
of s ngth d
in t tay,
r ea
d
ting elay
pat
ien other
ts
1
29
en
d
d
Hi es
s
los
300
Re
put
a
def tion,
ens staf
f
ive
wo moral
rkin
e,
g
es
s
s
e lo
bl
i
g
an
Int
Source: HSE (1997)
Typical total costs of a claim
Lacerations, minor scars---------£0-10k
 Missed/delayed fractures--------£10-25k
 Surgery to remove surg. mat.---£25-50k
 Damaged organs, footdrop-----£50-100k
 Fail sterilisation = live birth----£100k-1.13m
 Paraplegia, blindness-----------£250-500k
 Quadriplegia, brain damage--£500k-4.5m
 Death---------------------------------£10-250k

Adverse incidents
Adverse incidents occur in 10% of
hospital admissions
 37% of these result in disability
 8% result in death

Source: Vincent, Neale and Woloshynowych BMJ
2001;322:517-519 ( 3 March )
Comparative SWGH figures
using UCL study

38,000 in-patient episodes pa (including
Day Case) of which:
– 3800 inpatient adverse incidents
– 950 moderate or permanent impairment
– 304 deaths
Incident investigation findings
Under-reporting of incidents
 Records

– indecipherable
– undated/not timed
– no author
– non-existent
– no reason for treatment/test
Causes of incidents (NHSLA)

Failure to monitor, observe, or act

Delay in diagnosis

Incorrect risk assessment (for example,
of suicide or self harm)

Inadequate handover

Failure to note faulty equipment

Failure to carry out preoperative checks
Causes of incidents

Not following an agreed protocol
(without clinical justification)

Not seeking help when necessary

Failure to supervise adequately a junior
member of staff

Incorrect protocol applied

Treatment given to incorrect body site

Wrong treatment given
Incidents
The conjunction of…
Reason, Human Reliability (1989)
Incident Investigation
Proximate causes
 Sub-proximate causes
 Root causes

Root causes reveal areas which if
changed reap the greatest benefit.
Incident example
68 year old female patient brought to A/E
by ambulance with non-descript chest
pain. Admitted to a medical ward and
treated for thrombosis. Heparin written
up for 24 hour period. Delayed KCCT
test showed hypersensitivity to heparin.
Blood not clotting. Patient had lung
haemorrhage, subsequently arrested
and died.
Proximate causes
Differential diagnosis
 Patient weakened by morphine
 Lung haemorrhage
 Sensitivity to heparin
 Sensitivity not detected
 Prolonged use of heparin
 No protamin administered

Sub-Proximate Causes
KCCT test not carried out in adequate
time
 Protocol for heparin administration not
followed
 Conflicting advice in use of Protamin

Root Causes
Procedure for receiving Telephoned lab
results LTA
 Lack of advanced diagnostic services
 Inadequate Portering staff at the
weekend
 Procedure for urgent sample test LTA
 Training, supervision and information for
Junior Doctors LTA
 Protocol for Protamin not communicated

Incident Investigation
“Any accident is more tragic
if human experience is
none the richer for it.”
A.D. Craven: Safety and Accident Prevention in Chemical Operations
Recommendations
Review clinical incidents
 Make accurate, timely, identifiable,
legible records
 Review the patient when making
potentially serious interventions
 Act within level of competence
 Keep up to date
