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Transcript of Patient Safety in Women’s health: View from the National Observatory Prof James Walker Clinical...
Patient Safety in Women’s health:View from the National Observatory
Prof James Walker
Clinical Associate
National Patient Safety Agency
Background
The NPSA:• was established July 2001
• is a Special Health Authority
• has been created to co-ordinate efforts to identify and learn from patient safety incidents
Clinical Governance
Governance Developed: • An organisation with a memory, which looked at
learning from adverse incidents in the NHS; and • Building A Safer NHS for Patients, which set out the
government’s plans to address OWAM’s recommendations.
Why is patient safety important?
Medicine in the old days was simple, safe and ineffective.
Now it is complex, very effective but potentially dangerous
Sir Cyril Chantler,Chairman of the King's Fund Chairman of Board
GOSH
0
50
100
150
200
250
300
350
400
450
1935 1940 1945 1950 1955 1960 1965 1970 1975
Source: General Register Office and OPCS, Reproduced in Birth counts, Table A10.1.3. Graph by Alison Macfarlane
Dea
ths
per
100,
000
tota
l birt
hs
Abortion and miscarriage
Prolonged labour, trauma and other causes
Toxaemia
Haemorrhage
Puerperal sepsis
Puerperal phlebitis, thrombosis and embolism
Maternal mortality by cause (E&W) 1935-78
Maternal Mortality in Iraq
Maternal Mortality in Iraq
• Massive Obstetric Haemorrhage 28%• Post Abortion 19%• Eclampsia 17%• Infection 15%• Post Anaesthetic and Other 14%• Obstructed Labour/Ruptured Uterus 7%
Obstetric Claims
• Obstetric claims account for over 70% of all NHS litigation expenses with an average cost of cerebral palsy cases of £1.5m.
• Current estimate that obstetric claims amount to £400m of total £600m projected NHS costs.
Source:
Learning from litigation: an analysis of claims for clinical negligence
Vincent, Davy, Esmail, Neale, Elstein, Cozens, Walshe
August 2004
A problem in maternity services?
• Findings from root cause analyses of 37 adverse events/near misses in obstetrics (Ashcroft, 2002)– in 92% cases there no guidelines or protocols to advice on
clinical practice or organisational issues– 49% members of staff were unfamiliar with labour ward
protocols and failed to follow them
• CEMD report ‘Why mothers die 1997-1999’ highlighted need for guidelines to be used– “women are still dying of potentially treatable conditions
where the use of simple diagnostic guidelines may help”
Fire risk
"First, Do No Harm"
• Most practitioners are caring individuals– Highly skilled– Highly trained
• But we still make mistakes• Usually in repetitive (normal) tasks
– Omission
• It is not usually the emergency
Problems for the Beaver
• Learn task but watching and doing– Trial and Error
• Learning ends with the accident– No audit trail of problems– No “system” memory
• No guideline development• Continued accidents• The system is inherently dangerous
Safety First
• Simplifying and encouraging reporting of safety incidents
• More rapid reporting and notification of serious incidents to the NPSA within 36 hours leading to more rapid learning
• Capturing risky situations • Using patient safety data to inform
learning and action locally – analysis, learning and feedback.
Safety First highlights key areas for improvement in current safety reporting systems in the NHS. These include:
Event Reporting
• Mainstay of risk management • Part of every-day practice• Within the airline industry
– routine error (near miss) reporting followed by root-cause analysis and risk management, has led to a 4 fold reduction in major airline incidents
Error Analysis
• The traditional way
– person approach
– individual involved is questioned
– the problem tackled at that level
• Tackling the individual
– does not remove the pre-existing risk of error
– the error trap
Person Approach
• "If a surgeon has made a deep incision in the body of a man with a lancet of bronze and saves the man's life, or has opened an abscess in the eye of a man and has saved his eye, he shall take 10 shekels of silver.
• If a surgeon has made a deep incision in the body of a man with his lancet of bronze and so destroys the man's eye, they shall cut off his hand”– Laws of Hammurabi, Babylon, BC 1792
Root-cause analysis of major airline events
• Failure to follow accepted procedures • Misinterpretation of instruments • Incorrect decisions • Ignoring advice from colleagues • Failure of team working • Equipment failure • Pilot error
Themes from systematic review of the data
• High proportion of incidents reported relate to Trust maternity ‘trigger list’ categories
• Following these the top five themes are: – Communication– Staffing levels– Medication– Equipment– Patient ID
Reason’s ‘Swiss cheese’ model
some holes dueto active failures
other holes due tolatent conditions
hazards
losses
defences. barriers and safeguardsJames Reason 1997
System Approach
• Wider in its remit
– more open
– based on concept of system failures
– Different outcome for the individual
– more likely to produce solutions
• reduce the chance of recurrence.
• requires trusting environment
– a ‘no blame’ approach
Systems Approach
• More comprehensive covering
– The person
– Team
– Procedure
– Environment
– Organisation
Systems Approach
• Not
– ‘who made a mistake’
• but
– ‘how and why have the defences failed’
“We can’t change the human condition, but we can change the conditions under which humans work”
James Reasons
Solution
Defences, barriers, and safeguards
• Technical– alarms, physical barriers, automatic shutdowns
• Human – doctors, midwives, administrators
• Documentation– guidelines, standard operating procedures
• Act to – prevent error– protect the patient
• Defences are mostly successful– but not infallible.
Safety
• Driving is safer– Design
• Speed limits• ABS
– Safety• Car design• Seat belts• Airbags
• We are not better drivers
Increasing the number of Barriers to prevent Patient Safety Incidents
Swiss Cheese
Cheddar Cheese
Guidelines
• Keep them simple• For routine things
• Use checklists
• Use audit of practice
Are they effective?
“The distribution of methodologically sound clinical guidance does not, however, ensure
implementation”
The Obstetrician & Gynaecologist, 2001, p93
Guidelines
• Too many• Too complicated
• End unto themselves• Job is done
• Not proven or validated
Yorkshire Guidelines
• Consensus guidelines– Obstetricians and Anaesthetists– All units in Yorkshire
• Commenced May 1997 • By 1999, all units using• Regional audit of cases
– Each hospital auditing own cases– Regional co-ordination– Collection of data
0
5
10
15
20
25
To
tal
No of cases Stay over 24hours
Ventilated
1998
1999
2000
2001
ICU admissions in Yorkshire
Airline industry similar to medicine
• requires concentration – long periods of little activity– sudden emergencies – instant decision making
• team working which is interdependent
In Medicine
• Experts often not present at time of crisis
• (a latent failure)
– be aware of the possibility of failure
– be prepared to recognise and recover
• Assess possible risks
– risk assessment
• Rehearsing familiar scenarios
– Drills
• Common sense training
Drills and Skills
• Teach basic skills– For all
• Multidisciplinary– Team working
• Update
Airline industry
• Guidelines for the routine• Check lists
• Drills for emergencies• Experience for the unusual
• If they make a mistake - they die too
Designing out faults
• Copied from industry
• Assess the environment leading to the event
• Design solutions
– Training/supervision
– Design equipment/Hospital
– Encourage change in behavior
• (Guidelines)
a) periodically plot spillage area on an X-bar chart, look for special causes (audit)
b) double the size of the fixtures (prevent)
c) hire an attendant to monitor and reprimand “less hygienic” users (supervise)
d) Hand out guidelines on entry to toilet
what would you do?
Source: Wall Street Journal, used by John Grout,NPSA Seminar, 17 January 2003
JFK International terminal men’s restrooms
e) etch the image of a fly on the porcelain - (Focus)
Source:Wall Street Journal, used by John Grout,
NPSA Seminar, 17 January 2003
JFK International terminal men’s restrooms
Drug Administration
Fully assess risk
• Past history• Woman’s understanding of the risk• Flagging of the problem• Notifying
– (warning/planning)• Guidelines
What about Obesity?
• Increasing problem • Not allowed to talk about
it• We do not weigh people
any more• Ignore the problem• Wait for the disaster
Approach to Risk
You need to know: Min age is 12. Max weight is 16st. Min height is 4'11''. Unsuitable for pregnant women or anyone unable to climb up into the cockpit or fit in a standard car seat.
You need to know: Full manual driving licence required. As a guide max weight is 16st to 18st and you should be between 5'1'' and 6'4''.
Solution Development Processes
• Understanding the what, how and why• Identify potential solutions• Risk assess solutions• Pilot and learn • Implementation • Evaluation and impact assessment
Where are we now?
• Guidelines to inform– Routine
• Checklists to focus– Prompts– Memory aids– Care Bundles
• Drills for skills– Regular – For all
• Audit trail – Prove what you do
We need to share the learning from our mistakes to try and stop them happening
again …..