1 Learning when things go wrong Marg Way Director, Clinical Governance Alfred Health, Melbourne
2 Safety and Quality Management in hospitals Things have changed a lot over the last 10 years..
6 HOSPITAL catastrophes killed 29 Victorians in the past year Scores more were harmed by operations on the wrong patient or body part, overdoses and surgical equipment sewn into patients. Over the last 7 years, in Victoria : Procedures involving the wrong patient or body part 137 Suicide in an inpatient Unit 42 Retained instruments or other material 50 Blood transfusion ABO incompatibility 6 Medication error leading to death 16 Maternal death or serious morbidity 28 Other catastrophic event 350
7 The problem with safety in healthcare Quality in Australian Health Care Study 1 in 1995 found: 16% hospital admissions were associated with an adverse event 51% judged to be preventable 5% resulted in death Preventable cost - 5% of healthcare budget Human costs -?? Estimates of Preventable Deaths 10,000 pa in Australia 38,000 pa in UK 98,000 pa in USA Public Failures Bundaberg King Edward Memorial
8 Analysis of hospital failures Failure to learn Closed culture unsupportive of openly disclosing errors and adverse events Failure by management to respond effectively to known clinical problems Nonexistent or ineffective systems to monitor, report and respond to performance problems, errors and adverse events Poor communication with patients and families, particularly when things went wrong Poor management of complaints and potential medical negligence cases Inadequate training and credentialing to ensure clinicians were sufficiently skilled Inadequate morbidity and mortality monitoring and review systems Poor clinical and emotional outcomes for patients and families
9 Public Alerted! Demand Safer Care
10 Elements of Open Disclosure Expression of regret Factual explanation of what has happened Outline of potential consequences Steps being taken to manage the event and to prevent recurrence
11 Imagine you re in a hospital (!)
12 Scenario 1 3 days post-operative, worsening overnight, nurse concerned, reviewed by covering medical officer Patient critical on medical review next morning Patient died later that day Family complained they felt there was a delay in the diagnosis of perforated bowel How would a hospital know about this case? How would a hospital review this case? What would you tell the family?
13 Scenario 2 During routine death review, an autopsy report revealed the cause of death for a patient was pulmonary embolus which occurred 7 days postoperatively following transfer from another hospital Anti-coagulation therapy was not received post-operatively The family have also referred the case to the Coroner How would a hospital know about this case? How would a hospital review this case? What would you say to the family?
14 What impact does the approach taken by a hospital have on open disclosure? For our staff? For our patients?
15 The way we do things around here When I filled in a sentinel event form for it was downgraded from a sentinel event form to a less serious form and we didn t hear anything about it. if we see something that is wrong we should report it, but often these incident reports would disappear into a black hole.. Bundaberg Hospital - Commission of Inquiry 2005
16 Clinical Governance - A Framework for Action
17 The Patient is at the Centre If you can see things from the patient's eyes, go through the journey that you expect your patient to take you will discover a host of things that will cost very little to put right and will make your operations run far more smoothly.
18 The way we do things around here Identify serious incidents quickly Encourage Early Reporting Feedback Team discussions Build Trust Identify incidents waiting to happen - WalkRounds
19 Go looking for safety issues Some error traps in health care are obvious
20 What do we tell staff to report? If it doesn t seem quite right Staff / Environment Related Patient Related concerning: Patient identification Diagnosis Treatment Medications Communication Equipment Staffing Supervision Information/guidelines
21 What if this incident was not reported?? Photo - US Naval Safety Centre website
22 What if this incident was not reported?? What if it was dismissed as a near miss? the staff were too scared to report it? the systems and processes that led to this happening were not reviewed? the staff member driving the forklift had been killed or seriously injured? Photo - US Naval Safety Centre website WHAT IF THE BOMB HAD EXPLODED?
23 Managing Adverse Events and Incidents Event Occurs Manage the Event Notifications Patient and staff safe Immediate actions Open Disclosure Report the Event Incident reporting system Management oversight Investigate the Event RCA / case review Progress with patient Learn from the Event Recommendations / actions Meet with patient/ family
24 Supporting Staff Commend staff for reporting Assure staff that they will not lose their job Help staff to explain to their peers using the 4 Qs Could it happen to anyone? - Are there system issues? Could it happen again? Call for action Could it happen again tomorrow? Any action today? Can anything be done to prevent it happening again? Provide support to staff who were involved Debriefing, counselling, peer support Encourage staff to help get the analysis right I m not sure if it is important but..
25 Decision tree for possible culpability in clinical adverse events 1. Knowing violation of accepted standards of care (includes protocols)? No Pass the substitution test? Yes History of unsafe acts? Yes Were the standards well known, workable, intelligible and correct? Yes Possible gross negligence No Systeminduced violation Deficiencies in training, selection or accreditation? No Possible negligence No Yes Systeminduced error Yes Blameless error but training or counselling needed No Diminishing culpability Blameless error Modified from Reason, J. Managing the risks of organisational accidents, 1997
26 Principles for conducting incident analysis Focus on systems and processes Fair, thorough and efficient Focus on solving problems Use recognised analysis methods Use a scale of effectiveness to develop recommendations
27 Most important of all Implement effective changes Most effective Least effective Rating 1 Rating 2 Rating 3 Rating 4 Rating 5 Rating 6 Rating 7 Eliminate the risk Design for minimum hazard eg: Remove concentrated potassium in the wards Install safety devices eg: Automatic flow cut off when giving set removed from infusion pump Use cautions and warnings eg: Ventilator alarms, coloured syringes, stickers Control through procedures or administrative controls eg: Guidelines and protocols Personnel action by training or knowledge eg: Inservices or orientation Accept the remaining risk Adapted from Victorian DHS draft RCA Training Program module 3
28 Staff training in error recognition and management Training staff not to work harder not to be more careful To recognise error- provoking situations To put in defenses and barriers to prevent accidents happening To redesign the system use of incident analysis Photo - US Naval Safety Centre website
29 Supporting patients Has the patient been informed of the incident? Who informed patient: ie: Department Head, Medical Director, staff involved in incident Has any necessary treatment been given to correct any effects from the incident? Is any follow-up required with the patient, and who is responsible for this?
30 Customer Orientation People don t care how much you know. until they know how much you care
31 How many patient complaints do we receive each year? A) 10,000 B) 1,000 C) 100 D) 10 C) 1
32 Alfred Health Complaints - Annual 900 complaints 400 liaisons These are good numbers if we know about an issue, we can do something about it. Proactive intervention is important Get involved early Listen to the patient and family Get the facts Provide an explanation and an expression of regret if appropriate
33 How many patients successfully sue each year? 10,000 1,
34 How many patients successfully sue us each year? No successful cases No cases went to court A small number were settled Settled by Insurer with no costs to hospital or staff involved
35 What do people who complain or sue really want? Prompt response at the time Deal with any sequealae eg: additional treatment, charging Senior clinical staff / Chief Medical Officer To find out what happened and why To hear an apology, a condolence or an expression of regret To prevent it happening again To be compensated for costs incurred eg medical expenses, loss of earnings
36 Examples of improvements MET Stickers in the Medical Record Communication & Handover A Medical Emergency Team call occurred Important information about the medical emergency Clear plan for follow- up after a MET call
37 Examples of improvements Warfarin Discharge Form
38 Case Study First Sentinel Event ( reported to Department of Health) Reported to State Coroner Root Cause analysis undertaken Chambers Finding provided to Hospital Supplementary information provided about the actions taken to prevent recurrence Letter to family, expressing condolences and actions taken Commendation received from State Coroner Staff anxiety reduced No Inquest and Issue resolved Subsequent claim from family - settled
39 Always remember we are dealing with people trying to do their best Put a good person in a bad system and the bad system wins, no contest. (W. Edwards Deming) Source of photo: US Naval Safety Center Website
40 What does Clinical Governance mean? If you were explaining to your Mum There is a system to identify incidents and hazards Staff know how to report issues Staff feel safe to report Issues are followed up promptly Issues are taken seriously Action is taken to prevent problems recurring Patients are informed about the outcomes of their care The Board monitors safety and quality and is kept informed of any system failures and remedial actions taken
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