Post Fellowship Skills Course Background to Patient Safety Post Fellowship Skills Course

Patient Safety is... ‘The avoidance, prevention and improvement of adverse outcomes or injuries stemming from the process of healthcare’ (Vincent, 2006)

Policy Theory

SPSP Mental Health Maternity SPSP SPSP - Sepsis/VTE Revision of goals at the end of the first phase of Acute Adult Programme Primary Care SPSP Mental Health Maternity SPSP - Sepsis/VTE Medicines Management Network Safety in Primary Care SPSP Paediatrics SPSP 5 Acute Adult Care Workstreams Safer Patient Initiative 5 Acute Care Workstreams: Critical Care, General Ward, Periop, Leadership, Medicines 2005 2007 2008 2009 2010 2011 2012 2013 2014 Beyond

Patient Safety in Context 7 UK NHS organisations Failure rates (13-19%) Wide variation in reliability 1 in 5 operations involved wrong, faulty or missing equipment or staff didn’t know where it was or how to use it. 50% went well Delays and threats to patient safety http://www.health.org.uk/publications/research_reports/evidence_in_brief.html May 2010

>60% preventable 28% negligence ‘this was not my fault’ Leape L et al. Preventing medical injury. Quality Review Bulletin, 1993,8:144-149

We all make mistakes !

So poor communication is one of the main reasons for things going wrong in healthcare but there are other reasons , but why with all the good intentions and talent available in medicine, are clinical processes backed by solid medical advice carried out at such low levels of reliability? IHI identify 3 main reasons for the gaps in healthcare reliability.

Current improvement methods in healthcare are highly dependent on vigilance and hard work… from R Resar, Institute for Healthcare Improvement

All defects in process do not lead to bad outcomes…. from R Resar, Institute for Healthcare Improvement

from R Resar, Institute for Healthcare Improvement Permissive clinical autonomy creates and allows wide performance margins…. from R Resar, Institute for Healthcare Improvement

Systemic Migration to Boundaries INDIVIDUAL BENEFITS ‘ Driving 60 mph- the ‘Illegal-normal’ space (for almost all of us!) Belief Systems. Life Pressures Driving 80 mph – the ‘illegal-illegal’ space The posted speed limit is 50 mph- the ‘legal’ space VERY UNSAFE SPACE Perceived vulnerability ACCIDENT PERFORMANCE

Systemic Migration to Boundaries INDIVIDUAL BENEFITS ‘ Belief Systems. Life Pressures Only wash hands on audit days Handwashing when patient has MRSA Handwashing – every patient, every time VERY UNSAFE SPACE Perceived vulnerability ACCIDENT PERFORMANCE

Labels of Reliability For healthcare processes where failure does not cause immediate catastrophic consequences 80% performance lacks consistent clear understanding of the process (5 front line process users can not easily articulate the process) - chaotic process 95% performance has some variation but 5 front line users can easily articulate the process (These are IHI definitions and are not meant to be the true mathematical equivalent)

Improvement Concepts Associated with 80-90% Performance (Primarily can be described as intent, vigilance, and hard work) Common equipment, protocols, and written policies/procedures Personal check lists Feedback of information on compliance Suggestions of working harder next time Awareness and training 18 18

Improvement Concepts Associated with 95% or Better Performance (Uses human factors and reliability science to design sophisticated failure prevention, failure identification, and mitigation) Decision aids and reminders built into the system Redundant processes utilised Habits and patterns known and taken advantage of in the design Standardisation of process 19

Clinical Governance Strategy 2013 – 2016 Adverse event management

Copies available

Discuss in your groups an incident that you have been involved in. Identify things that went wrong in the system due to the way it was designed or managed. What improvement concepts could be tested to improve the reliability gaps that you have identified?

Safety is a moving target Harm has been defined too narrowly Seeing safety through the eyes of the patient Consequences for incident analysis