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
APHA 33 rd National Congress Open Disclosure Workshop with Case Studies Presented by Dr Chris Beck, Prof Rick Iedema, Dr John Wakefield, and Shane Evans 25 March 2014 ME_112150592 A. Overview and Framework
Activities for MANAGERS Australian Safety and Quality Framework for Health Care Putting the Framework into action: Getting started Contents Principle: Consumer centred Area for action: 1.1 Develop methods
Georgene Saliba MBA, CPHRM Administrator, Risk Management & Patient Safety Lehigh Valley Health Network Allentown, PA Objectives Define Enterprise Risk Management(ERM) and its application when managing
Review of the Department of Health and Human Services management of a critical issue at Djerriwarrh Health Services November 2015 Review Panel Adjunct Professor Debora Picone AM Mr Kieran Pehm Contents
6 Complaints Even the most careful and competent dental professional is likely to receive a complaint about the quality of the service, care or treatment they have provided, at some point in their career.
WELFARE OF ANAESTHETISTS SPECIAL INTEREST GROUP Resource Document 23 (2011) COMMUNICATION AND CONSENT: YOUR BEST DEFENCE INTRODUCTION Recent studies, both in Australia and overseas, have confirmed that
NHS Complaints Advocacy Raising Concerns or Complaints About the NHS Advocacy in Surrey is provided by Surrey Disabled People s Partnership (SDPP) In partnership with SDPP is a registered Charity: 1156963
Disclosing Medical Errors to Patients: Developing and Implementing Effective Programs Thomas H. Gallagher, MD University of Washington School of Medicine Accelerating Interest in Disclosure Growing experimentation
THE WESTERN AUSTRALIAN REVIEW OF DEATH POLICY 2013 Department of Health, State of Western Australia (2013). Copyright to this material produced by the Western Australian Department of Health belongs to
Document Information Board Library Reference Document Author Assured By Review Cycle P033 Head of Risk & Compliance Quality & Healthcare Governance 3 Years Note: This document is electronically controlled.
SOURCE: Ministry of Health DATE APPROVED: DATE EFFECTIVE: Date of Approval REPLACESPOLICY DATED: 1 POLICY TITLE: Incident/Accident Reporting REFERENCE NO. MOH/04 PAGE: 1 of 7 REVISION DATE(s): Ministry
Patient, family, carer and support person evaluation survey template DATE: Australian Open Disclosure Framework Supporting materials and resources Open Disclosure: Patients, families, carers and support
49th Annual Meeting Preventing Medication Errors in a Just Culture Environment Disclosure I do not have a vested interest in or affiliation with any corporate organization offering financial support or
Improving open disclosure in Dutch hospitals Kiliaan van Wees and Lodewijk Smeehuijzen/VU University, Amsterdam Introduction Previous research project Open Communication and Compensation following adverse
: A guide to making a claim 2 Our guide to making a clinical negligence claim At Kingsley Napley, our guiding principle is to provide you with a dedicated client service and we aim to make the claims process
Guide to the National Safety and Quality Health Service Standards for health service organisation boards April 2015 ISBN Print: 978-1-925224-10-8 Electronic: 978-1-925224-11-5 Suggested citation: Australian
Proposed Apology Legislation: from the Medical Perspective Dr David Dai JP Consultant Physician Member of the Working Group on Apology Legislation Of the Steering Committee on Mediation 11 July, 2015 The
A Guide to Accident Investigations Introduction The Health and Safety Executive (HSE) report that in 2010/2011 171 workers were killed at work. A further 121,430 other injuries to employees were reported
Our specialist team has a wealth of knowledge and experience in dealing with claims arising from clinical negligence. We work in a supportive, considered & clear way, dedicated to gaining the best possible
Statutory duty of candour with criminal sanctions Briefing paper on existing accountability mechanisms Background In calling for the culture of the NHS to become more open and honest, Robert Francis QC,
DNV Healthcare Maternity Quality and Risk Forum Alison Bartholomew Director of Business Development, Baby Lifeline Training Ltd December 2013 - London Ensuring the healthiest outcome possible from pregnancy
POSITION DESCRIPTION POSITION TITLE REPORTS TO AWARD/AGREEMENT/CONTRACT POSITION TYPE HOURS PER WEEK Nurse Unit Manager Business Director of Ambulatory and Continuing Care Professional Executive Director
PS035 Original research completed in 2010 Briefing Paper Introduction: Principal Investigator: Professor John Clarkson Should the NHS adopt a new system for predicting possible risks to patient safety?
Buyers Up Congress Watch Critical Mass Global Trade Watch Health Research Group Litigation Group Joan Claybrook, President S. 1784 Encourages Providers and Insurers to Voluntarily Report Medical Errors,
Guide to Complaint Handling in Health Care Services Health Services Review Council Health Services Review Council 2005 Health Services Review Council Steering Committee: Michael Gorton (President 2004)
Action against Medical Accidents response to the Consultation on proposals to reform Fatal Accident Inquiries legislation Introduction 1. Action against Medical Accidents (AvMA) was established in 1982.
WITHDRAWAL OF LIFE SUPPORT BACKGROUND The complainant s wife was admitted to a public hospital for an operation to secure access for peritoneal renal dialysis. At the time of the patient s admission she
Guide to to good handling of complaints for CCGs CCGs May 2013 April 2013 1 NHS England INFORMATION READER BOX Directorate Commissioning Development Publications Gateway Reference: 00087 Document Purpose
Occupational Health and Safety Division Elements of an Occupational Health and Safety Program Table of Contents Introduction 3 What workplaces must have a program? 5 What criteria must the program meet?
Trust Board 8 May 2014 Title of the Paper: Quarter 4 (1 st January 2014 31 st March 2014) CLIPS Report Agenda item: 205/17 Author: Jackie Ardley, Interim Chief Nurse Trust Objective: 1) Achieving continuous
Office for the Community Sector Quality and Safety Standards Framework for Tasmania s Community Sector A Proposed Way Forward Consultation Paper September 2008 1 Contents: Page 1.0 Background 3 2.0 Tasmania
Step-by-step guide to pursuing a medical negligence claim Suffering from medical negligence can be a painful and distressing experience for anyone. This short guide offers some advice to help people thinking
BIO INFOBK 1492 0410:Layout 1 21/04/2010 15:24 Page 1 INFORMATION LEAFLET You are being invited to take part in a major medical research project called UK Biobank. The purpose of UK Biobank is to set up
The Australian Charter of Healthcare Rights in Victoria The Australian Charter of Healthcare Rights in Victoria The Australian Charter of Healthcare Rights The Australian Charter of Healthcare Rights describes
Patient Safety and Clinical Quality Program Second report on incident management in the NSW public health system 2004 2005 NSW DEPARTMENT OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel. (02) 9391
Topic 5 Learning from errors to prevent harm 1 Learning objective Understand the nature of error and how healthcare providers can learn from errors to improve patient safety 2 Knowledge requirement Explain
Su p O er D se : d 05 e d 21 b /1 y: 4 Clinical Incident Management Policy Department of Health 2012 This policy integrates the: Clinical Incident Management Policy using the Advanced Incident Management
Playing it safe: Hints to avoid a claim Presentation to University of Melbourne Students Disclaimer: The information in this presentation is general information relating to legal and/or clinical issues
RMP. South Tyneside NHS Foundation Trust Policies and Procedures Policy on the Handling of Complaints Approved by Trust Board December 2006 (revised version approved by RMEC May 2010) Policy Type Policy
Justice Committee Apologies (Scotland) Bill Written submission from the Law Society of Scotland Introduction The Law Society of Scotland (the Society) aims to lead and support a successful and respected
IT S OK TO SAY I M SORRY Anything you say can and will be used against you in a court of law. We are all familiar with this phrase from the Miranda warning. It essentially advises a person accused of a
CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 1/1/213 to 31/12/213 CLIPS Report (Complaints, Litigation, Incidents, PALS and Safeguarding) 1. Introduction On a quarterly basis,
Incident reporting procedure Number: THCCGCG0045 Version: V0d1 Executive Summary All incidents must be reported. This should be done as soon as practicable after the incident has been identified to ensure
MODULE 4 QUIZ Legal Issues in Documentation 1. From a legal standpoint, failure to document client care means which of the following? a. The care provider made errors b. Care provider forgot to document
PRODUCT LIABILITY Product Liability Litigation The Effect of Product Safety Regulatory Compliance By Kenneth Ross Product liability litigation and product safety regulatory activities in the U.S. and elsewhere
Dr. Safaa Hussein Mohammad Lecturer Medical &Surgical Nursing ISSUES IN RISK MANAGEMENT - The legal setting - Malpractice - Avoid Malpractice - The medical record - Patients rights Identifying and analyzing
A review into the quality of NHS complaints investigations where serious or avoidable harm has been alleged EMBARGOED COPY Not to be published in any form EMBARGOED COPY Not to be published in any form
MAURICE BLACKBURN LAWYERS MEDICAL NEGLIGENCE SOUTH AUSTRALIA 02 MAURICE BLACKBURN YOU RE WORTH FIGHTING FOR. If you are hurt, injured, or are facing an unfair situation, you and your family shouldn t have
Written Evidence Apologies (Scotland) Bill The Law Society of Scotland s Response May 2015 The Law Society of Scotland 2015 Introduction The Law Society of Scotland (the Society) aims to lead and support
Risk Management and Patient Safety Evolution and Progress Madrid February 2005 Charles Vincent Professor of Clinical Safety Research Department of Surgical Oncology & Technology Imperial College London
Process for reporting and learning from serious incidents requiring investigation Date: 9 March 2012 NHS South of England Process for reporting and learning from serious incidents requiring investigation
Why clinical risk is relevant to patient safety? Workshop on Clinical Risk Management and Management of Adverse Event Belgrade 16-17 December 2013 Dott.ssa Lucia Guidotti Ministry of Health, Department
Department of Veterans Affairs Office of Inspector General Report No. 14-03927-197 Office of Healthcare Inspections Healthcare Inspection Patient Telemetry Monitoring Concerns Michael E. DeBakey VA Medical
Additional Copies To obtain additional copies of this report, visit the Web site of the Department of Defense Inspector General at http://www.dodig.mil/audit/reports or contact the Secondary Reports Distribution
June 2015 Going to a Mental Health Tribunal hearing Includes: information about compulsory treatment and treatment orders information about Mental Health Tribunal hearings worksheets to help you represent
The State Claims Agency Clinical Indemnity Scheme Incident Notification Requirements. Preface The Clinical Indemnity Scheme (CIS) was established in July 2002, within the State Claims Agency (SCA), (S.I.
Standard 1 Governance for Safety and Quality in Health Service Organisations Safety and Quality Improvement Guide 1 1 1October 1 2012 ISBN: Print: 978-1-921983-27-6 Electronic: 978-1-921983-28-3 Suggested
Managing the Risk of Work-related Violence and Aggression in Healthcare Information Sheet November, 2014 The purpose of this information sheet is to provide information and guidance on managing the risk
Factsheet 66 August 2011 Resolving problems and making a complaint about NHS care About this factsheet The factsheet explains the approach to handling complaints about National Health Service (NHS) services,
March 10, 2015 CONFERENCE CALL DOCUMENTATION FOR C.N.A.s Presented by Dwana Jackson, CNA, AIPP Quality Specialist Good morning everyone and welcome to today s conference call, our topic today is documentation
Your rights if you have been injured as a result of treatment If you have had medical treatment which went wrong or caused you injury, you are entitled to full explanations and you may be able to get compensation
Service Making a Silk Purse out of a Pigs Ear Susan Brandis Associate Professor Director Clinical Governance Gold Coast Australia Fast growing (4.6% pa) with a projected population of 560,318 by 2016 Over
ENC 5 Meeting Trust Board Date 18 th December 2014 Title of Paper Lead Director Author Improving Services for Patients with Learning Difficulties Kathryn Halford, Director of Nursing Jennifer Robinson,
UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST CLINICAL NEGLIGENCE, PERSONAL INJURY, AND PROPERTY CLAIMS HANDLING POLICY APPROVED BY: THE TRUST BOARD DATE: 6 TH JUNE 2002 REVIEW: ORIGINATOR: ANNUALLY MICHAEL
Guide to making a complaint about an NHS service February 2014 Healthwatch Coventry www.healthwatchcoventry.org.uk Contents 1. About this guide page 3 2. The NHS complaints procedure page 3 3. About the
www.personalinjury.ffw.com Freephone 0800 358 3848 www.personalinjury.ffw.com Freephone 0800 358 3848 Medical Negligence A client s guide head and shoulders above the rest in terms of skills, experience
www.ffw.com/personalinjury Freephone 0800 358 3848 www.ffw.com/personalinjury Freephone 0800 358 3848 Medical Negligence A guide for clients The team provides a first class service at all levels of experience.
Claim Management Policy REFERENCE NUMBER Claim management policy VERSION V1.0 APPROVING COMMITTEE & DATE Clinical Executive Committee REVIEW DUE DATE May 2018 1 West Lancashire CCG is committed to ensuring
Policy and Procedure for Claims Management RESPONSIBLE DIRECTOR: COMMUNICATIONS, PUBLIC ENGAGEMENT AND HUMAN RESOURCES EFFECTIVE FROM: 08/07/10 REVIEW DATE: 01/04/11 To be read in conjunction with: Complaints
Policy Document Control Page Title Title: Personal Injury and Clinical Negligence Claim Policy Version: V5 Reference Number: CO18 Supersedes Supersedes: V4 Description of Amendment(s): Harmonisation with
Promoting a Culture of Quality Jonathan Welch, M.D. Brigham and Women s Hospital Boston, Mass. S. Allan Adelman, Esq. Adelman, Sheff & Smith, LLC Annapolis, Md. As She Lay Dying: How I Fought to Stop Medical
A Review of the NHSLA Incident Reporting and Management and Learning from Experience Standards Assessment Outcomes April 2003 - March 2004 September 2004 1 Background The NHS Litigation Authority (NHSLA)
Medication safety in Australia an overview Margaret Duguid Pharmaceutical Advisor Australian Commission on Safety and Quality in Health Care 30 October 2009 Medication safety and quality Medications are