Patient Safety: Why Hospitals Should Fly

21
Why Hospitals MUST Fly! Risk Assessment Approach to Health Care Acknowledgements to J Nance Sue Hendy 1

description

Sue Hendy, Director, Women's Children & Youth Services Obstetric & Gynaecology Department, from Westmead Hospital, Western Sydney Local Health District has presented at the Obstetric Malpractice Conference. If you would like more information about the conference, please visit the website: http://bit.ly/10xh1iO

Transcript of Patient Safety: Why Hospitals Should Fly

Page 1: Patient Safety: Why Hospitals Should Fly

Why Hospitals MUST Fly!

Risk Assessment

Approach to Health Care

Acknowledgements to J Nance

Sue Hendy

1

Page 2: Patient Safety: Why Hospitals Should Fly

Objective

Human Factors in healthcare

Clinicians and women

Environment system and culture

Leader versus commander

Inspire you to view world in a different way

2

Page 3: Patient Safety: Why Hospitals Should Fly

Deaths in Healthcare due to adverse outcomes likened to

aircraft disasters & 100% mortality

Risk Rating

Activity Deaths/1m people/year

Deaths/100m hrs of exposure

Being pregnant 150 1

Being in traffic (overall in any capacity) 15,000 50

Flying in commercial aircraft 50 100

Being a patient in acute care hospital 33,000 2,000

Safety & Ethics in Healthcare: Getting it Right: Runciman et al 2007

Page 4: Patient Safety: Why Hospitals Should Fly

Events %

Problem with or failure of an op or procedure 18%

Hospital acquired infection 16%

Wrong, delayed or missed diagnosis or treatment 14%

Complication of a body system

Hospital acquired injury

Medication error or problem with a drug

11%

8%

7%

Page 5: Patient Safety: Why Hospitals Should Fly

5

Page 6: Patient Safety: Why Hospitals Should Fly

Anne Walsh-Plaintiff Lawyer :

Quotes from Day 1

• We all do things wrong everyday

• Speak up if something is wrong

Page 7: Patient Safety: Why Hospitals Should Fly

4 Pillars

• Clinicians

• Women

• Environment, system and culture

• Leaders ability and style

Page 8: Patient Safety: Why Hospitals Should Fly

National Registration

(ANMC) Competency Standards

Clinical Guidelines

Peer & Multidisciplinary review

SAC 1 sentinel event: death, severe disability

Root Cause Analysis

SAC 2 – near miss

8

Page 9: Patient Safety: Why Hospitals Should Fly
Page 10: Patient Safety: Why Hospitals Should Fly

Question?

10

Page 11: Patient Safety: Why Hospitals Should Fly

E

Environment, system and culture:

Minimise human error through training, procedural adherence, checklists, evaluations & standardisation

Build the system to fully expect and be able to safely absorb those errors that will still occur

BUT….

DESPITE all the training, and the buffers there is at least a 50% chance of something going wrong at any time

Page 12: Patient Safety: Why Hospitals Should Fly

“Alas, culture is not what we

say, what we think, what we

mean, or even what we intend;

.”

Jon Burroughs, MD

12

Page 13: Patient Safety: Why Hospitals Should Fly

Leadership

Oppression Theory

Major characteristics of oppressed behavior

stem from the ability of dominant groups to

identify the “right” norms and values & from their

power to enforce them.

13

Page 14: Patient Safety: Why Hospitals Should Fly
Page 15: Patient Safety: Why Hospitals Should Fly

15

Page 16: Patient Safety: Why Hospitals Should Fly

HIERARCHY

Staff complain to mgror each other

Boss solves problems

People know their place

No feedback sought

Secrecy and blame

Control as key

Different rules for different roles

16

Page 17: Patient Safety: Why Hospitals Should Fly

17

Page 18: Patient Safety: Why Hospitals Should Fly

We Need a Patient Safety System

Built to Serve the Woman , not just the doctor or staff!

In which doctor is the TRIBAL LEADER, not the COMMANDER.

In which collegial interactive teams are not just a STANDARD, they’re a CORE VALUE!

Page 19: Patient Safety: Why Hospitals Should Fly

19

We need a SYSTEM in which…

The absence of collegiality is NOT TOLERATED by anyone at any time for any reason.

The goal of absolute Patient Safety is a CORE

VALUE, not a top-down driven ideal

Every participant takes pride in how they’ve adapted to being an Imperfect Human.

19

Page 20: Patient Safety: Why Hospitals Should Fly

20

We Need a SYSTEM in which…

ABUSIVE BEHAVIORS or ABUSIVE ABSENT BEHAVIORS are not tolerated by ANYONE.

Every person enthusiastically accepts

responsibility for every patient & every situation

they encounter

Anyone can take care of your Loved One.20

Page 21: Patient Safety: Why Hospitals Should Fly