2. Understanding Human Error in Healthcare
Patient Safety:
Understanding Human Error in Healthcare

3. Aims To develop the knowledge, skills and attitudes that promote:
the reduction of medical error to improve patient safety
learning from error in healthcare to improve patient safety

4. Learning Outcomes Knowledge What is a medical error?
How and when does this happen?
How do people make errors?
Why do people make errors?
What happens when an error is made?
How do people feel when they make errors?

5. Learning Outcomes Skills Recognition of error Dealing with error
Reporting and learning from error
Supporting others involved in error

6. Learning Outcomes Attitudes Focuses on cause rather than culprit
Willing to learn from mistakes
Being prepared to acknowledge and deal with error
Being prepared to reflect on practice
Trust and respect

7. Introduction and Background
Human Error- “We cannot change the human condition, but we can change the conditions under which humans work”.
(James Reason BMJ March 2000)

8. Personal vs System Approach
Personal approach
focuses on the unsafe acts
“sharp end”- name and shame
System approach
errors seen as consequence not cause
aim to build defences and safeguards
Health care – now learning from other industries
High technology systems have many defensive layers - like a Swiss cheese
Active failures
Latent conditions Reason BMJ March 2000

9. Some 'holes' due to active failures Other 'holes' due to latent
DANGER
Some 'holes'
due to active
failures
Defences
in depth
Other 'holes'
due to latent
conditions
From Reason 1997

10. Definitions
Adverse patient incident - any event or circumstance arising during NHS care that could have or did lead to unintended or unexpected harm, loss or damage.
Harm - injury (physical or psychological), disease, suffering, disability or death.
Incidents that lead to harm- Adverse Events.
Incidents that do not lead to harm - Near Misses.
Other terms which may be used - clinical incident, critical incident, serious untoward event, significant event
(National Patient Safety Agency 2001)

11. What is happening? – the world
Australia – Australian Patient Safety Foundation – established as an association 1989
USA – National Patient Safety Foundation – established 1998
Canada – Canadian Patient Safety Institute established 2003
WHO – World Alliance for Patient Safety launched 2004

12. What is happening? - UK
High profile reports of errors leading to patient morbidity and mortality e.g. Bristol
Department of Health publish - “An Organisation with a Memory”
National Patient Safety Agency established in England
to improve safety of patients by promoting a culture of reporting and learning from patient safety incidents

13. National Patient Safety Agency
The National Reporting and Learning System on patient safety incidents
Aims:
To identify trends and patterns and underlying causes
To develop models of good practice at national level
To improve working practice by feedback and learning
To encourage education and training (NPSA: Seven steps to patient safety, Nov 2003)

14. Discussion If people try hard enough they will not make any errors
If we punish people when they make errors, they will make fewer of them

15. Extent and Nature of Adverse Events in Healthcare
850,000 adverse events per year (NHS)
44,000 incidents fatal
Half are preventable
Accounts for 10% of admissions
Costs the service an estimated £2 billion per year (additional hospital stays alone, not taking into account human or wider economic costs e.g. litigation)

16. Factors Contributing to Human Error
Environmental Factors
Light
Noise and Vibration- Alarms!
Temperature
Humidity
Restrictive/ protective clothing
Equipment layout and design
Physical environment

17. Factors Contributing to Human Error
Some examples of personal factors
Fatigue
Stress
Workload
Distraction
Drugs/ Alcohol
Hypoglycaemia
Hypovolaemia

18. Professional Cultural Issues Underlying Error
A definition of culture
“how we do things around here”

19. Reporting Systems Some National Examples Some Local examples
Scottish Audit of Surgical Mortality
National Confidential Enquiry into Patient Outcome and Death
Why Mothers Die: Report on Confidential Enquires into Maternal Deaths in the UK
The Confidential Enquiry into Stillbirths and Deaths in Infancy
Yellow Card - BNF
Royal College of Anaesthetists - Critical Incident Reporting
Scottish Confidential Audit of Severe Maternal Morbidity
Some Local examples
OR1 forms / Medication Error reporting forms
Significant Event Analysis in General Practice
Risk management and M&M meetings
Paediatric Surgical error Book

20. Factors Contributing to Successful Error Reporting
Culture - just, reporting, flexible, learning
Treats less experienced staff as professionals
Accept human fallibility – even good doctors!
Training on safety issues
Annual appraisal
Ground rules established - acceptable and unacceptable behaviour
Support / trust / leadership
Well run - good input and change implemented with good communication
Consistency
Clear instructions
Anonymity
Confidential
Voluntary

21. Barriers to Successful Reporting
Fear of individual / organisational repercussion
Defining reportable errors too narrowly
Length of contract / time in job
Workload involved - usually time (form filling)
Culture of fear of “losing an otherwise good nurse / doctor”
Where reporting has not brought about change
Uncertainty right and wrong - differing opinions

22. Disclosure What does it feel like? What needs to be done?
Write it all down
Document in the patient’s notes
Tell your consultant
Local reporting system
Write to GP?
Tell the defence union
COMMUNICATE! Patient and their relatives

23. Communication
Needs to be handled carefully- all parties in highly charged emotional state
Relatives- distressed / anxious / angry
Health workers- panic / guilt / uncertainty / anxiety
CALM
Enlist help of colleague
Statement of situation and apology
Bad news given - recipients should be offered privacy, access to phones, offers to call family / friend
Organise future meeting
from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

24. Meeting with Relatives/ Patients
Ensure all facts are collected and available
If patients have special needs- arrange interpreters
Mutually convenient time
Comfortable environment- no interruptions eg staff / phones / bleeps
Introduce yourself clearly
Establish who is present and why
Explain how the meeting will progress
from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

25. Meeting Explain facts in clear, jargon - free language
Identify unresolved issues and ensure these are being investigated further
Patients current condition and probable outcome should be described honestly
Check on understanding
from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

26. Language Try not to attribute blame unless clear cause
Express regret - “We are extremely sorry that your…”
Avoid comments like “ I can understand how upset you must be”
Rather “In similar circumstances I think most people would feel as you do now, but I can assure you that we want to help you to deal with it”
Person apologising on behalf of the organisation - impartial(?)
Be prepared for a variety of emotional reactions
from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

27. Plan Outline what treatment plan is now being undertaken
Reassure that all possible measures are being taken to resolve harm done
Explain what is being done to prevent same thing happening again
Arrange further meeting if appropriate
Offer a break?
Procedures for compensation
Emotional support
Details about full inquiry
CONCLUSION
from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

28. Support Systems Your colleagues! Doctors Plus Sick Doctors Trust
See patient safety website for details
Sick Doctors Trust
For doctors who are suffering from addiction
A Framework of Support
GMC
National Counselling Service for Sick Doctors
The British Doctors and Dentists Group
BMA Stress Counselling Service