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1. 2 Patient Safety: Understanding Human Error in Healthcare.

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Presentation on theme: "1. 2 Patient Safety: Understanding Human Error in Healthcare."— Presentation transcript:

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2 2 Patient Safety: Understanding Human Error in Healthcare

3 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 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 5 Learning Outcomes Skills –Recognition of error –Dealing with error –Reporting and learning from error –Supporting others involved in error

6 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 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 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 9 Defences in depth Other 'holes' due to latent conditions Some 'holes' due to active failures DANGER From Reason 1997

10 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 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 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 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 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 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 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 17 Factors Contributing to Human Error Some examples of personal factors –Fatigue –Stress –Workload –Distraction –Drugs/ Alcohol –Hypoglycaemia –Hypovolaemia

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

19 19 Reporting Systems Some National 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 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 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 22 Disclosure What does it feel like? What needs to be done? –Write it all down –Document in the patients notes –Tell your consultant –Local reporting system –Write to GP? –Tell the defence union –COMMUNICATE! Patient and their relatives

23 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 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 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 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 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 28 Support Systems Your colleagues! Doctors Plus –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

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