Senior Lecturer Primary Health Care and General practice "Patient Safety Investigation" or "Disciplinary Process to Find Fault " how do we decide? Dr Ben Gray GP Convener Professional Skills Attitudes and Ethics University of Otago Wellington Senior Lecturer Primary Health Care and General practice

My Credentials GP for underserved population Expert Witness before Health Practitioners Disciplinary Tribunal One patient subject of Severity Access “1” patient safety report Two patients subject of complaint investigation by HDC Many clinical episodes that if complaints had been lodged I may have been disciplined.

Terminology Adverse Event Adverse Outcome Sentinel Event Medical Error Patient Safety Incident Complaint

Patient Safety Incidents Sentinel events Adverse outcomes Preventable adverse events Adverse events Medical errors Complaints = Juliet Broadmore 2006

James Reason Intrathecal Vincristine Fatality http://www.who.int/patientsafety/education/vincristine_download/en/ Patient injected vincristine intrathecally and died. 14 previously documented episodes. Operating procedure developed to try to avoid a repeat. Brian Toft. External Inquiry into the adverse incident that occurred at Queen’s Medical Centre, Nottingham, 4th January 2001. In: United Kingdom Department of Health, editor. London 2001. Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. 2004. p. ii28-33.

Person approach to Error The longstanding and widespread tradition of the person approach focuses on the unsafe acts—errors and procedural violations—of people at the sharp end: nurses, physicians, surgeons, anaesthetists, pharmacists, and the like. It views these unsafe acts as arising primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness. The associated counter measures are directed mainly at reducing unwanted variability in human behaviour. These methods include poster campaigns that appeal to people's sense of fear, writing another procedure (or adding to existing ones), disciplinary measures, threat of litigation, retraining, naming, blaming, and shaming. Followers of this approach tend to treat errors as moral issues, assuming that bad things happen to bad people—what psychologists have called the just world hypothesis.

System approach to Error The basic premise in the system approach is that humans are fallible and errors are to be expected, even in the best organisations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in “upstream” systemic factors. These include recurrent error traps in the workplace and the organisational processes that give rise to them. Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work. A central idea is that of system defences. All hazardous technologies possess barriers and safeguards. When an adverse event occurs, the important issue is not who blundered, but how and why the defences failed.

The Swiss cheese model of accident causation The Swiss cheese model of accident causation. The slices of cheese represent successive layers of defences, barriers, and safeguards. Reason, J Qual Saf Health Care 2004;13:ii28-ii33 Copyright ©2004 BMJ Publishing Group Ltd.

Qualifications Not about egregious behaviour “Incidents that involve a criminal act, or substance abuse by the health practitioner, a deliberate unsafe act, or a deliberate consumer harm” Public Hospital Incidents

Differences in two investigation systems. Health and Disability Commisstion Health Quality and Safety Commission New (2-3yrs) System set up in public hospitals Patient Safety incident; could be complaint, bad outcome, staff report Triaged and coded All Severity Assessment Criteria 1-2 investigated Investigation done by clinical team leader and patient safety officer. Well established Triggered by complaint Complaints triaged ++++ Formal investigation triggered. Investigation by officer at HDC Involve named clinical advisors Decision made by Commissioner (deputy)

Differences between HDC and HQSC Investigation Processes (1) What happened? Health Quality and Safety Health and Disability The “truth” (like seeing the video) - Face to Face reports + Written reports Freely given recall without threat of repercussion Legally edited recall Written documents (patient notes) Soon after (1…….5) much later 1-3 3-5

Differences between HDC and HQSC Investigation Processes (2) The Investigator Health and Disability Health Quality Safety Investigator at a distance Investigating officer with advice. Dependent on advice about the system Investigator on site Senior Clinician . Good understanding of system within which incident occurred

Differences between HDC and HQSC Investigation Processes(3) Focus Health and Disability Health Quality Safety Response to complaint. Dual role, to determine If there was a breech and quality improvement Response to patient safety incident. Single role: quality improvement

Differences between HDC and HQSC Investigation Processes(4) Report and Recommendations Health and Disability Health Quality Safety Report delayed often 2 years External recommendations ? Less likely implementation Report within months Internal recommendations ? more likely implementation

Differences between HDC and HQSC Investigation Processes(4) Limitations Health and Disability Health Quality Safety Few serious events complained of. Conflict between goals, leads to limiting quality of information Findings usually limited to the individuals and institution rarely outside of institution. Cost/Resource Use Dependent on trustworthy implementation of HQSC guidelines Assurance of “no retribution” limits response to finding egregious behaviour. One purpose is to look for wider systems problems. Cost/resource use