A Review of Serious Incident Investigation Reports from the years :

Transcription

1 A Review of Serious Incident Investigation Reports from the years : Identifying patient safety issues that emerge from an overview analysis of national data. Author: L Mullen Date: 20th June 2013

2 Background There is concerted effort to develop Quality and Patient Safety structures and initiatives within the HSE. The need to demonstrate that the HSE is responding and doing what needs to be done arising from its serious incident investigations has become more acute. This includes learning from both international evidence and the completed investigations of serious incidents. It is the policy of the HSE that the commissioners of investigations are responsible for ensuring the implementation of locally applicable recommendations. Where nationally applicable recommendations are identified in investigations the commissioner must arrange for these to be communicated to the relevant National Director for national implementation (HSE 2009, and HSE 2012). This report summarises findings from a retrospective qualitative sampling and analysis of regional and national incident reports completed between It is intended to provide an additional analysis of the health services which have been subject to serious incident reports and identify care delivery problems and their contributory factors which frequently re occur as patterns or themes in the serious incident reports and are modifiable through initiatives taken on a national basis. Quality and Patient Safety developments in the HSE are ongoing and are based on international evidence on patient safety. Many elements of healthcare that harm patients are known and modifiable with robust patient safety awareness and systems. Initiatives are currently in place in the HSE on a local and national level. A review of completed investigation reports was undertaken with an aim to identify nationally applicable trends and learning. Relevant literature and data base systems were also reviewed. 2

3 Methodology A request was made by the National Director of Quality and Patient Safety for this qualitative review to be undertaken. In order to obtain a comprehensive review of completed serious incident and death investigation reports between the years a letter of request was drafted and sent. The letter was sent to the Regional Directors of Operations, Area Managers for Quality and Patient Safety and the National Ambulance Service from the National Director of Quality and Patient Safety. The letter requested an electronic copy of all completed serious incident and death investigation reports between the years The copies were to be sent securely through internal and password protected. Each report was printed, made available to the researcher and stored securely. The electronic copies are also held in a secure central location. The researcher separated the reports by region and took a sample from each region for in depth review and analysis, (table 1.). Table 1. Number of Reports Reviewed by Region of the HSE Reviewed reports Total number of reports Percentage of reports reviewed DML % DNE % South % West % Totals % Reports were read carefully for content, themes and issues emerging. A template was created for the extraction of data. A qualitative analysis identified themes emerging from the reports. The emphasis in the analysis is on contributory factors and issues that can be addressed at a national level. 3

4 Reports completed by national agencies and reports completed by the National Incident Management Team (NIMT) in the time period were also reviewed. A list of these reports is contained in appendix 1. Results The results are presented in two parts. In the first section a table is given which provides examples of the type of care delivery problems identified in the reports and some of the contributory factors associated with these problems. This is not a fully comprehensive table of every care delivery problem or every stated contributory factor. The table illustrates the most common problems identified and gives of flavour of the essence of the reviewed reports (Table 2). The second section of the results contains the thematic findings of the analysis and discussion of some key issues that arose from the review of the reports. It is important to state that many reports contained a systems analysis approach which included a care and management review. These care and management reviews often found that the care and management of the patient was in keeping with expected practices and standards. In a number of reports reviewed no care delivery problems were identified. 4

5 Table 2. Examples of Care Delivery Problems and Contributory Factors found in the Review of Completed Serious Incidents and Death Reports Care Delivery Problems Missed diagnosis and failure to manage full injuries Contributory Factors Failure to conduct requested diagnostic tests Deteriorating condition undetected Failure to recognise and manage severity of condition within acceptable timeframe Delayed recognition of an acute deterioration Failure to order appropriate tests PEWS did not identify deteriorating condition Failure to document clinical assessment by other specialist consultation Healthcare Aquired Infection in patients (HAI), Management of HAIs Delay in the early recognition and treatment of sepsis Hygiene standards Single source documentation Busy ED, Language barrier, communication between specialist teams, NCHDs not responding, documentation not recorded/timed, unclear treatment plan Difficulties recognising patients deteriorating condition, delay in response Failure to diagnose the cause of presenting symptoms Urgent reports were not written into chart but communicated verbally Multimorbidity in patient 5

6 Patient management systems Delayed medical examination/tests No documentation, lack of definitive working diagnosis, no written care plan No effective Multi Disciplinary Team (MDT) review Consent process was not documented No standardisation of preoperative marking Failure to carry out mandatory surgical safety checklist Delay in the investigation and management of clinically significant signs and symptoms, Inadequate documentation/ continuity of care Non adherence to policy and procedure Delay in reporting incident to management failure to arrange a follow up once diagnosis was made Key Thematic Issues There were five key thematic issues that arose from the review these were; documentation, the rapidly deteriorating patient, patient and family communication, not observing standard protocols and procedures and completed suicide. Documentation The reports contain comment and criticism of the quality and precision of documentation. This includes retrospective charting, charts which do not contain information on time and person making note, time periods in which little documentation occurs on notes or documentation of a superficial and unsatisfactory quality. These findings are made in a number of unrelated incident reports, in different care settings and across regions. The lack of 6

7 accurate descriptive documentation is a common problem as is the failure to comply with the record management policy of the service. Overall many reports comment that the quality of patient records is poor. Other contributory factors to poor patient safety involving documentation are; nonadherence to standard practice and policies, skill mix of staff contributing to documentation and follow up systems, turnover and changeovers of staff and services at high patient capacity. Rapidly deteriorating Patient The incident investigation reports contain evidence that failure to recognise rapidly deteriorating patients is leading to death and serious harm. It is identified by the investigators as a care delivery problem in a substantial number of investigations. Combined with failure to recognise symptoms and subsequent failure to send for tests and inadequate monitoring it is the most common cause in this dataset of serious death and harm. This category is a common patient safety issue internationally. This review of reports is occurring at a time a number of initiatives such as early warning systems and guidelines are being implemented. It will take time for these initiatives to be fully implemented and vigilance will need to be continued after implementation in order to insure that policies and procedures are always adhered to. In a number of cases reviewed standardised policies and procedures were in place but were not followed. Other issues are communication between specialties and the culture and practice of MDT review including the ordering of tests by different specialities, follow up of tests and discrepancy meetings. Communication of unexpected clinically significant, or urgent findings between teams can be an issue as can report turn around time, and completeness. 7

8 Patient and family communication The reports contain evidence through patient interviews and patient s complaints that patients and families often drew attention to the patient being in a deteriorating state. There was a number of reports that contained formal complaints by patients and families. There was a sense of not being listened to or being kept in the dark about issues in relation to patients care. There were a number of reports in which consent issues arose and policies and procedures were not adhered to by the service. There is a need to ensure a policy for management of patients re presenting to the ED with the same complaint with in a defined timeframe. As more cohesive medical records systems are developed and there is a move to electronic patient records, one record will contain all the information available for every consultation which will facilitate better patient management systems. Not observing standard protocols and procedures In a number of the sampled reports there was evidence that guidelines and protocols were in place but were not followed. This includes the failure to order appropriate tests and provide follow up consultations. This resulted in missed diagnosis and failure to manage full injuries of patients. In many cases the deteriorating condition of the patient went undetected. In a number of reports it is clear that team reviews did not take place, and there were problems of communication breakdown at handovers, and between specialty teams. There was some highlighting in the reports of over crowding/ reduced staffing and more junior medical staff being present. Suicide There were a large number of investigation reviews of completed suicides of patients in both inpatient, acute and out patient care. A number of patients had been in the care of mental health services for a number of years. There 8

9 were both patient and situational factors that were identified. In some cases no care delivery problems were identified. A large number of the suicides were in patients who currently or in the past attended mental health services in the HSE. Mental illness is a known risk factor for suicide and it current best practice to assess and monitor for suicidal ideation. There are a number of guidelines and protocols in place in the various settings to risk manage suicide and it is known that patients most recently discharged from acute care are identified as being among the highest risk of suicide. This is a very difficult phenomena that would benefit from an in depth specialist review of cases. A small group of mental health professionals should conduct a review and identify international best practice in this area and how the HSE might prevent and reduce the number of cases of completed suicide. Impression of investigations. This piece of work does not contain a formal assessment of the quality and completeness of investigations and investigation reports. Nevertheless a number of general comments can be made about the reports as reviewed for this report. The reports are variable in terms of whether or not they are in the standard HSE format. This improves in the latter reports from the time period. It is worth monitoring the use of standardised investigation methods and report formats as it results in a much clearer and more comprehensive picture and is much easier to draw conclusions from. Reports benefit from the summary section contained within the standardised report. This could also be further reduced to a one page cover sheet with essential data and summary. A summary sheet would also aid categorisation of reports by region, type of incident, patient factors, care delivery problems and contributory factors. It is recommended that when a system of annual review of reports is in place that regular audit of reports should be done. This could be on the basis of 9

10 reviewing all reports or just those that are classified under an incident classification, location or service of interest. The reports obtained can form the basis of a repository. There will need to be some classification of reports. This repository can be regularly reviewed and interrogated for different purposes such as review of a particular patient safety issue or research with appropriate protections. It would also aid an annual review and report on cases. All reports should be stamped or marked confidential in an electronic form. This is not the case at present. Summary Many of the issues identified in this review are consistent with the findings of national independent investigations and inquiry and international findings. A number of initiatives have been developed and implemented in the years since these reports were written and the incidents took place. These initiatives such as the early warning scoring system (2011), publishing of the HSE standards and recommended practices for healthcare record management (V3.0, 2011) and the National Consent Policy (2013) take time to be implemented and embedded within the health system. They will support better patient safety practices and culture in the future. This report has found a number of issues that would benefit from further patient safety initiatives and development, the culture of situational awareness and robust systems and management. This exercise will be performed prospectively in the future as better systems and structures are in place for investigation review. This will facilitate the timeliness of review and improve safety for all patients. 10

11 Appendix 1 Document List HSE Incident reporting guidance Toolkit of documentation to support the health services executive incident management. HSE, March 2009 Incident management policy and procedures. HSE, 2008 Serious incident management policy and procedures. HSE, 2008 Guidelines for systems analysis investigation of incidents and complaints. HSE, November References Patient safety: from learning to action Fifth Queensland health report on clinical incidents and sentinel events in the Queensland public health system, and State of Queensland, 2012 National Reports and Inquires HIQA Report of the investigation into the quality and safety of services and supporting arrangements provided by the Health Services Executive at the Mid Western Regional Hospital Ennis. April Report of the investigation into the quality and safety of services and supporting arrangements provided by the Health Services Executive at Mallow General Hospital. April Report of the inquiry into the circumstances that led to the failed transportation of Meadhbh McGivern for transplant surgery and the existing inter agency arrangements in place for people requiring emergency transportation for transplant surgery. August

12 Report of the investigation into the quality, safety and governance of the care provided by the Adelaide and Meath Hospital, Dublin incorporating the National Children s Hospital (AMNCH) for patients who require acute admission. May Mental Health Commission Report of the committee of inquiry to review care and treatment practices in St. Michael s unit, South Tipperary General Hospital, Clonmel and St. Luke s Hospital, Clonmel, including the quality and planning of care and the use of seclusion and to report to the Mental Health Commission. MHC Confidential maternal death enquiry in Ireland. Report for the Triennium MDE August HSE (National Incident Management team) National Miscarriage Misdiagnosis Review. April Patient Transfer report review. August