Why clinicians make mistakes and what we can do about it Matilda International Hospital

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1 Imperial College London Why clinicians make mistakes and what we can do about it Matilda International Hospital P J Steer Emeritus Professor of Obstetrics Academic Department of Obstetrics and Gynaecology Chelsea and Westminster Hospital 5 th October 2014

Emeritus Professor of Obstetrics Academic Department of

2 From the 1970s it has gradually dawned upon us that the quality of medical care has not been as good as we had hoped

3 EFFECTIVE MEDICAL CARE IN PATIENTS ATTENDING AN A&E DEPARTMENT: Only 27% received effective care Brook, RH, et al (1973) Annals Intern Med

4 IATROGENIC ILLNESS IN A UNIVERSITY HOSPITAL GENERAL MEDICAL CLINIC 36% of 815 consecutive patients had an iatrogenic illness in 9% this was life-threatening or produced disability Steel et al (1981) N Eng J Med 304;

iatrogenic illness in 9% this was life-threatening or

5 ADVERSE EVENTS AND INAPPROPRIATE CARE IN ADULT ITU/SURGERY UNITS 1047 patients reviewed at three University Hospitals in Chicago and Florida 185 (17.7%) patients had at least one serious adverse event related to inappropriate care only 13 (1.2%) made claims for compensation Andrews, LB (1997) Lancet 349;309-13

(17.7%) patients had at least one serious adverse event related to

6 ADVERSE EVENTS IN BRITISH HOSPITALS Care of 50 consecutive adult emergency patients before admission to ITU studied 37 (69%) were admitted too late up to 41% of admissions were avoidable Suboptimal care contributed to morbidity or mortality in most cases McQuillan P et al (1998) BMJ 316;

up to 41% of admissions were avoidable Suboptimal care contributed to

8 KGMM ALBERTI, PRESIDENT, ROYAL COLLEGE OF PHYSICIANS

9 AN AUDIT OF THE FIRST ANTENATAL VISIT 115 women had a previous baby <10th centile History only noted in 37 (32%) Almost half of these women were booked for inappropriate antenatal care Chng et al (1980) Br J Obstet Gynecol 281;

Almost half of these women were booked for inappropriate

10 AUDIT OF COMPLIANCE WITH ANTENATAL PROTOCOLS 2000 women delivered at the Homerton Hospital to ,658 actions dictated by Hospital protocols 3,673 (23.5%) actually performed Yoong et al, (1992) BMJ 305;

11 AUDIT OF COMPLIANCE WITH ANTENATAL PROTOCOLS (2) % of women with an abnormal history referred for a consultant opinion: eclampsia <1% proteinuria at booking <1% preterm labour 24% stillbirth or neonatal death 43% Yoong et al, (1992) BMJ 305;

eclampsia <1% proteinuria at booking <1% preterm labour 24%

12 Obstetric accidents review of 64 MPS cases Number of cases Cardiotocography not done 11 Unsatisfactory trace 6 Trace recorded but missing 19 CTG abnormality not noticed, or ignored 14 CTG abnormality noted and responded to 14 Total 64 Ennis M, Vincent CA. (1990) BMJ 300:

but missing 19 CTG abnormality not noticed, or ignored 14 CTG

13 Obstetric accidents review of 64 MPS cases Grades of doctors initially contacting the Medical Protection Society Senior House Officer Registrar Senior Registrar Consultant Other Total No of cases Ennis M, Vincent CA. BMJ 300:

House Officer Registrar Senior Registrar Consultant Other

14 Obstetric accidents review of 41 AVMA cases Inadequate fetal monitoring and insufficient supervision of junior doctors were implicated in a high proportion of accidents Some junior doctors and midwives cannot recognise abnormal CTG traces Most receive inadequate training in CTG monitoring Vincent CA, Martin T, Ennis M, (1991) BJOG 98:

accidents Some junior doctors and midwives cannot recognise abnormal CTG traces Most

15 Psychological aspects of error in CTG interpretation Emphasis in early 1990s on solo practice routine ward rounds discouraged We re nearly there so keep going Desensitization to developing problems can occur from watching a tracing for too long Gradual accumulation of abnormalities goes unnoticed Tiredness, overconfidence, inexperience

Desensitization to developing problems can occur from watching a tracing for too

CESDI 6th ANNUAL REPORT 1999 30 % 25 20 15 10 5 567 cases of poor outcome studied

16 CESDI 6th ANNUAL REPORT % cases of poor outcome studied 0 NO/NO YES/NO YES/POSS YES/YES Sub-optimal care preventable by better management

17 CTG INTERPRETATION - THE HUMAN ELEMENT Fetal surveillance problems were the commonest cause (of problems in labour), with CTG interpretation.the most frequent criticism CESDI - 6th Annual report, June 1999

18 NHSLA study of 100 stillbirth claims July 2009

21 PERHAPS THE FAILURE OF CTG HAS NOT BEEN A FAILURE OF TECHNOLOGY - BUT A FAILURE TO APPLY IT PROPERLY SOLUTIONS MAY INCLUDE: Guidelines Improved training Improved audit Testing of competency Expert systems ( auto-pilots )

23 IMPROVED TRAINING S. Beckley, E. Stenhouse, and K. Greene. The development and evaluation of a computer-assisted teaching programme for intrapartum fetal monitoring. BJOG. 107 (9): , 2000.

24 Effect of audit and training on suboptimal intrapartum care - N Staffs Hospital Low Apgars - % suboptimal care % suboptimal care Baseline audit Regular low Apgar feedback meetings CTG training compulsory Young et al (2001) JRSM 94:

25 K2 training The 7th annual CESDI report recommended that interactive computer based training should be available to all staff involved in the management of labour. The Clinical Negligence Scheme for Trusts (CNST) now requires that staff in all maternity units in England receive training in the management of high risk labours and CTG interpretation every 6 months. >90% of UK maternity units use the system

26 Does training work? S. Beckley, E. Stenhouse, and K. Greene. The development and evaluation of a computer-assisted teaching programme for intrapartum fetal monitoring. BJOG. 107 (9): , 2000.

27 Pattern recognition? Some individuals may have intrinsic difficulty detecting the patterns in fetal heart rate traces A person with dyslexia correctly identifies the voice pattern in a person speaking his or her native language about 40% less of the time than a person without dyslexia. Perrachione TK, Science, 2011 Jul 29;333(6042):595 Kuhl PK, Science, 2011 Jul 29;333(6042):529-30

28 Testing of competency Pilots can expect to be tested about 100 times during their careers Doctors and midwives are only tested if there is a complaint

29 EXPERT SYSTEMS R. D. F. Keith, S. Beckley, J. M. Garibaldi, J. A. Westgate, E. C. Ifeachor, Greene, and KR. A multicentre comparative study of 17 experts and an intelligent computer system for managing labour using the cardiotocogram. Br J Obstet Gynaecol 102 (9): , 1995.

48 cases of stillbirth, NND and HIE amongst 530 labours 100 80 % detection 60 40 20

30 48 cases of stillbirth, NND and HIE amongst 530 labours % detection INFANT Expert 1 Expert 2 Expert 3 0 Stillbirth NND HIE For a similar false positive rate

31 The INFANT trial Intelligent Fetal AssessmeNT Randomised trial of decision support Automatic interpretation of CTG during labour HTA (health technology assessment programme) grant 5.9M Dec 2008

32 INFANT trial objectives 1. To determine whether decisionsupport can improve the management of labour using CTG. 2. To determine whether the use of the system is cost-effective.

33 Primary outcomes 1. Poor neonatal outcome : Deaths: intrapartum stillbirth Neonatal death Significant morbidity: seizures & other admission to NICU within 48 hrs of birth for 48 hrs with evidence of encephalopathy, feeding difficulties or respiratory illness 2. Developmental quotient at age 2 years

34 Sample size - neonatal outcome Assuming: Poor neonatal outcome 6.2 per 1000 α = 0.05 β = % reduction in poor neonatal outcome rate Need: 46,000 births in total (23,000 per arm)

36 Infant Ladder of Concern This ladder of concern is positioned next to the patient details and will indicate a colour coded system identifying any concern that it may have and highlight what the concern is.

37 Infant ladder of concern levels GREEN Indicates that there are no concerns with the CTG (level 4) BLUE Indicates that there are minor concerns with the CTG (level 3) YELLOW Indicates that there are serious concerns with the CTG (level 2) RED Indicates that there are urgent concerns with the CTG (level 1)

46 The study started in Blackburn on 4th January Sites have recruited cases Blackburn/Burnley Liverpool Warrington Derriford, Plymouth Q/A Portsmouth North Staffs Northwick Park Stoke Mandeville Homerton, London Warwick Nottingham Queens Derby Princess Anne Birmingham Women s Princess Royal St Mary s Manchester Southern General Nottingham City Queen s Medical Centre The Rotunda, Dublin Coventry Chelsea & Westminster Bolton UCLH

47 INFANT TRIAL Trial finished 2 nd September ,000 labours randomised Results due early 2015

48 Will INFANT work? May improve recognition of abnormality Insurers would not cover system making recommendations Failure to act may still be the key failing Major increase in training and testing will still be required

Why do people make mistakes?

Why do people make mistakes? - and what can we do about it? P J Steer Emeritus Professor of Obstetrics Academic Department of Obstetrics and Gynaecology Chelsea and Westminster Hospital 1 Imperial College