1 Module 4 Learning From When Things Go Wrong A Resource to Support Training Activity in Clinical Settings

2 Module summary Module 1 Principles of human error Module 2 Principles of risk assessment Module 3 Safer systems Module 4 Learning from when things go wrong

3 Learning Objectives By the end of the session participants will be able to: Describe and rationalise ‘Being Open’ process Understand the effects of patient safety incidents Identify the needs of patients following a safety incident Define & rationalise need for Root Cause Analysis Identify the basic elements of an RCA investigation List the contributory factors that underpin a RCA Understand the potential role for junior doctors in RCA

4 Session Outline Being Open Definition Patient testimony Effects of patient safety incidents What patients want Principles of ‘Being Open’ The ‘Being Open’ process Root Cause Analysis What is RCA? Why RCA? Elements of an investigation Classifying incidents Investigatory process Investigation team

5 Part 1 Being Open

6 What is ‘Being Open’? ‘Being Open’ involves apologising and explaining what happened to patients and/or their carers who have been involved in a patient safety incident. It ensures communication is open, honest and occurs as soon as possible following an incident.

7 ‘Being Open’ – the benefits Being Open can help patients cope better with the after-effects of a patient safety incident Being Open can help junior doctors reduce the demoralisation and distress caused by a patient safety incident Being Open can help the NHS reduce costs through litigation and further treatment – patients and carers are much less likely to complain or make legal claims if they receive an apology and an explanation

8 The Effects of Patient Safety Incidents

9 Patient/carer testimony 1 This video can be downloaded from atientsafety/improvingpati entsafety/learning- materials/safe- foundations// atientsafety/improvingpati entsafety/learning- materials/safe- foundations// Go to ‘modules’ and scroll down to ‘module 4’

10 Effects of Patient Safety Incidents Activity On Patients and/or Carers –How would you feel if you were the carer involved in this incident? –What 3 things do you think patients and/or carers involved in this type of incident would want most? On Healthcare Professionals –How would you feel if you had been the healthcare professional involved? –What would your concerns be in this situation or if you were involved in any patient safety incident? –What 3 things do you think patients and/or carers involved in this type of incident would want most?

11 What Patients Want The English public want: –34% an apology or explanation –23% an enquiry into the causes –17% support in coping with the consequences Less important were: –11% financial compensation –6% disciplinary action Source: MORI survey commissioned for the ‘Making Amends’ report, DOH, 2002

12 Patient Testimony 2 This video can be downloaded from atientsafety/improvingpati entsafety/learning- materials/safe- foundations// atientsafety/improvingpati entsafety/learning- materials/safe- foundations// Go to ‘modules’ and scroll down to ‘module 4’

13 Experience in the USA 50% fewer pending lawsuits Average litigation costs down to $35,000 from $65,000 Annual savings in one hospital - $2mn Source:

14 Saying Sorry – What & When “Initial explanations should focus on what happened and how it will affect the patient, including immediate effects & the prognosis. The caregiver should acknowledge the event, express regret & explain what happened. If an obvious error has been made, the caregiver should admit it, take responsibility for it, apologise, and express a commitment to finding out why it occurred. Typically, this should occur within 24 hours.” (Harvard Hospitals, 2006)

15 Part 2 Root Cause Analysis

16 Root Cause Analysis “…is a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened.” (Seven Steps to Patient Safety, 2004)

17 Why RCA? “In-depth analysis of a small number of incidents will bring greater dividends than a cursory examination of a large number” (Vincent & Adams,1999)

18 Why Root Cause Analysis? A rationale: A safe culture is informed by learning A learning culture requires an organisational memory This depends on the collection, analysis and dissemination of adverse event data A ‘reporting culture’ is more likely to generate a ‘learning culture’

19 Root Cause Analysis A methodology that enables you to ask the questions: 1.What? 2.How? 3.Why? NOT….”Who?” …in a structured and objective way.

20 Basic Elements of a Good RCA Investigation WHAT happened HOW it happened WHY it happened Unsafe Act (CDP/SDP) Human Behaviour Contributory factors

21 Contributory Factors Patient factors Individual factors Task factors Communication factors Team & social factors Education & training factors Equipment and resource factors Working condition factors Organisational & management factors

22 Activity Given that front-line staff are the most likely to be involved in patient safety incidents, identify, in pairs, 3 contributions to a Root Cause Analysis that you might make. 1.Classifying an incident 2.Providing full & accurate information to an investigation team 3.Participation in the investigation team

23 Classifying an Incident A Patient Safety Incident (PSI) is: Any unintended or unexpected incident(s) that could have or did lead to harm for one or more persons receiving NHS funded healthcare. Which PSI requires an RCA? PSI causing death or severe harm Frequently occurring PSI / Prevented PSI

24 Classifying an Incident Death Severe Moderate Low None Must always be considered for a causal analysis Should always be considered for a causal analysis The nature of the incident will determine whether there is causal analysis Not generally subject to causal analysis though there are exceptions Not generally subject to causal analysis except in aggregate

25 Classifying Incidents Consider the following two incidents: 1.A patient booked for an arthroscopy on the left knee has it performed on the right knee necessitating a repeat procedure and unnecessary pain & suffering (moderate) 2. A patient has presented frequently to the GP surgery with throat discomfort for one year and is finally referred to the ENT clinic. Patient is subsequently diagnosed with throat cancer. (severe)

26 Gathering Data / Info Mapping Data / Info Identify Care / Service Delivery Problems Analyse the Problem / Identify Root Causes Develop Targeted Recommendations Write Report Providing Information to an Investigation Team

27 RCA Investigation Team Incidents causing death or severe harm: Multidisciplinary group of 3-4 persons One of which should be fully trained in incident investigation and analysis Objective attitude Good organisational skills Use of experts (including those who were involved in the incident)

28 Reflection Identify 3 learning points: Identify 3 action points:

29 Reporting The vast majority of NHS care is safe and effective with over a million patients successfully treated every day. However errors do occur and the NPSA collects reports from healthcare staff and patients, to identify recurrent patient safety problems and develop national solutions. If doctors report locally, the NPSA will automatically receive this information. However, they also have the option of reporting anonymously online direct to the NPSA at