Transcript Slide 1
Safety First
– Accidents a Close Second!
Dr. Maureen Baker CBE DM FRCGP
Honorary Secretary
Promoting Excellence in Family Medicine
Overview
Background to the patient safety movement
An Organisation with a Memory
Seven Steps to Patient Safety
Future developments
Some definitions
Patient Safety – freedom from accidental harm
to individuals receiving healthcare
Patient Safety Incident – an episode when
something goes wrong in healthcare resulting
in potential or actual harm to patients
Is there a problem?
Studies based on retrospective analysis of medical
records :
Harvard study 1991 (Lucien Leape) – adverse
event rate in ‘hospitalisations’ of 3.7% of which
two thirds were ‘errors’
Australian study 1995 (Ross Wilson) – adverse
event rate 16.6%
British study 2001 (Charles Vincent) – adverse
event rate of 10.8%
To Err is Human (Institute of Medicine 1999)
As many as 98,000 people die
each year in USA from medical
errors that occur in hospitals.
That is more than die in RTAs
or from breast cancer or AIDS.
Medical error is fifth leading
cause of death in USA
An Organisation with a Memory
(CMO, 2000)
The NHS is doomed to
make the same mistakes
over and over again as we
have no way of learning
from when things go wrong
Disasters in other industries
Herald of Free Enterprise
Hillsborough
Sinking of Marchioness
on Thames
Bhopal
Learning from when disasters happen
Complex set of interactions
No single causal factor
Combination of local conditions, human
behaviours, social factors, organisational
weaknesses
Human Error (Reason, 1990)
Humans are fallible and
errors are inevitable
Systems approach takes
holistic view of causes of
failure
Cannot change the human
condition but can change
conditions in which people
work and minimise
opportunities for error
Reason’s Swiss Cheese Model
An Example
Systems Approach in Healthcare
As many as 70% of adverse incidents are
preventable
Errors can be minimised, but never completely
eliminated
Rarely single, isolated cause of error –
attempts to prevent errors need to address
systems as a whole
Safety Critical Industries with
Safety Approach
Aviation
Railways
Oil and Gas
Construction
Nuclear
Military
Learning from failure
“The NHS is not unique: other sectors have
experience of learning from failures which is of
relevance to the NHS”
Sir Liam Donaldson in
‘Organisation with a Memory’
Systems for Learning from
Experience : Aviation
Accident and serious incident investigations
Confidential Human factors Incident Reporting
Programme (CHIRP)
Company Safety Information Systems
Crew Resource Management
The Need for Action in Healthcare
Unified mechanisms for reporting and analysing
examples of when things have gone wrong
Development of a more open culture in which
errors or service failures can be admitted
Lessons must be identified, active learning must
take place and necessary changes must be put
into practice
Healthcare professionals must appreciate the
need to ‘think systems’ in learning from errors, as
well as in prevention through risk management
The National Patient Safety Agency
Established in 2001
Relates to England and Wales
Responsible for National Reporting and
Learning System (NRLS)
Previously produced Patient Safety Alerts
Now is developing systems of ‘Rapid
Responses’
Produced guidance to the NHS on patient
safety – ‘Seven Steps to Patient Safety’
Reported incidents by type
(NPSA, April 2006 – March 2007)
Reported degree of harm
Seven Steps to Patient Safety
The Steps
Step 7 - Solutions to reduce harm
Step 6 - Learn and Share Lessons
Step 5 - Patient involvement
Step 4 - Promote Reporting and Learning
Step 3 - Integrated Risk Management
Step 2 - Lead and support your staff
Step 1 - Build a Safety Culture that is open and fair
Step 1 - Build a Safety Culture that is
Open and Fair
Organisations, practices, teams and individuals
have constant and active awareness of
potential for things to go wrong
Being open and fair means sharing information
freely with patients and families balanced by fair
treatment for staff when things go wrong
Incidents are linked to the system in which an
individual works
Safety Culture
NPSA – A safety culture is where
organisations, practices, teams and individuals
have a constant and active awareness of the
potential for things to go wrong. Both the
individuals and the organisation are able to
acknowledge mistakes, learn from them, and
take action to put things right.
Confederation of British Industry – The way
we do things around here
Step 1 – Best Practice
Don’t expect perfection from humans – use
systems to support human decision making
Establish reporting systems for errors and
adverse events (practice; local; national)
Assess your culture by undertaking a practice
safety culture audit, eg MaPSaF
Step 2 - Lead and Support Staff
Delivering patient safety needs motivation and
commitment from clinical and managerial staff
everyone has a responsibility for safety
Leaders must be visible and active in leading
patient safety improvements
Staff and teams should be able to say if they do not
feel that care is safe – regardless of their position
Some ideas – patient safety champions; safety
briefings; team briefings; safety walkabouts
Step 2 – Best practice
Leadership – GPs and practice leaders have to
own safety. Walk the walk
Reflection – ‘How are we doing on safety?’
Training – Run in-house and seek out external
provision
Promotion – standing agenda item in clinical
and business meetings
Step 3 – Integrate risk
management activity
Proactive
Reactive
Training in safety and
Incident reporting and
risk
analysis
Use risk assessment in
Significant event audit at
major change
team or unit level
management projects
Root cause analysis at
Review controls for
organisational level
minimising risk
All of the above methods
can be integrated
Step 3 – Best Practice
Regular and embedded SEA in practice
Sharing the learning from SEA
Active and willing participation in other reactive
methods, eg RCA
Active participation in reporting systems
‘Should we report this?’
Embrace risk assessment methodology –
identify and manage your risks
Step 4 – Promote reporting
Reporting of patient safety incidents provides
the opportunity to ensure that learning from
what happened to one patient can reduce the
risk of the same thing happening to another
patient
Reporting should be simple, timely, confidential
(?anonymous), and have feedback
mechanisms
Step 4 – Best Practice
Report locally
Learn and share locally
Report nationally
Involve patients and public in reporting and
learning
Step 5 – Involve and communicate
with patients and the public
Patients’ expertise and experience can be used
to identify risks and devise solutions to patient
safety problems
Staff need to include patients in identifying
risks and in helping to protect themselves from
harm
Being open when things have gone wrong can
help patients cope better afterwards
Step 5 – Best Practice
Actively involve patients in safety culture and
activity eg section on safety in annual reports,
patient reps in risk assessments
Seek patient views and comments
Be open when things go wrong (‘Being open’
tool from NPSA available online)
Step 6 – Learn and share
safety lessons
Significant Event Audit
Developed in general
practice and promoted by
RCGP
Team based
Can link to conventional
audit
Can be themed
Powerful driver for
change
Learning can be shared
Root cause analysis
Intensive technique
Usually for most serious
incidents (deaths or
multiple cases of harm)
Normally at
organisational level
Requires trained
facilitators
Learning can be shared
Step 6 – Best Practice
Regular structured SEA meetings
Respond quickly when there are important
events or when high risks are identified
Involve patients
Learn lessons and put learning into practice –
don’t be doomed to see the same event
happening over and over again
Step 7 – Implement solutions to
prevent harm
Design systems that make it easy for people to
do the right thing and difficult for them to do the
wrong thing
Solutions that rely on physical barriers are far
more effective than those that rely on human
behaviour and action
Solutions should be risk assessed, evaluated
and sustainable in the long term
Step 7 – Best Practice
Actively consider solutions in SEA meetings
What have others done?
What ideas can we get from staff and patients?
Formal risk assessment of solutions
Share your solutions with others
Where are we now?
Increased awareness
Enlistment of stakeholders
Safety campaigns – 100,000 Lives in USA
Leadership - ‘Safety First’, Dec 2006
Translating to action?
What are they actually doing?
WHO – Safer Surgery
What is happening in New Zealand?
From ‘Seven steps’ to ‘Next steps’
Need safety culture to tackle safety problems,
e.g. Infection control needs ALL Seven Steps
Professional understanding and ownership –
especially safety culture and human factors
Work with safety professionals – a pilot or an
engineer on every Healthcare Board?
Research and evaluation to demonstrate
clinical and financial benefits