Safety First – Accidents a Close Second! Dr. Maureen Baker CBE DM FRCGP Honorary Secretary

Overview Background to the patient safety movement An Organisation with a Memory Seven Steps to Patient Safety Future developments

Some definitions Patient Safety – freedom from accidental harm to individuals receiving healthcare Patient Safety Incident – an episode when something goes wrong in healthcare resulting in potential or actual harm to patients

Is there a problem? Studies based on retrospective analysis of medical records : Harvard study 1991 (Lucien Leape) – adverse event rate in ‘hospitalisations’ of 3.7% of which two thirds were ‘errors’ Australian study 1995 (Ross Wilson) – adverse event rate 16.6% British study 2001 (Charles Vincent) – adverse event rate of 10.8%

To Err is Human (Institute of Medicine 1999) As many as 98,000 people die each year in USA from medical errors that occur in hospitals. That is more than die in RTAs or from breast cancer or AIDS. Medical error is fifth leading cause of death in USA

An Organisation with a Memory (CMO, 2000) The NHS is doomed to make the same mistakes over and over again as we have no way of learning from when things go wrong

Disasters in other industries Herald of Free Enterprise Hillsborough Sinking of Marchioness on Thames Bhopal

Learning from when disasters happen Complex set of interactions No single causal factor Combination of local conditions, human behaviours, social factors, organisational weaknesses

Human Error (Reason, 1990) Humans are fallible and errors are inevitable Systems approach takes holistic view of causes of failure Cannot change the human condition but can change conditions in which people work and minimise opportunities for error

Reason’s Swiss Cheese Model

An Example

Systems Approach in Healthcare As many as 70% of adverse incidents are preventable Errors can be minimised, but never completely eliminated Rarely single, isolated cause of error – attempts to prevent errors need to address systems as a whole

Safety Critical Industries with Safety Approach Aviation Railways Oil and Gas Construction Nuclear Military

Learning from failure “The NHS is not unique: other sectors have experience of learning from failures which is of relevance to the NHS” Sir Liam Donaldson in ‘Organisation with a Memory’

Systems for Learning from Experience : Aviation Accident and serious incident investigations Confidential Human factors Incident Reporting Programme (CHIRP) Company Safety Information Systems Crew Resource Management

The Need for Action in Healthcare Unified mechanisms for reporting and analysing examples of when things have gone wrong Development of a more open culture in which errors or service failures can be admitted Lessons must be identified, active learning must take place and necessary changes must be put into practice Healthcare professionals must appreciate the need to ‘think systems’ in learning from errors, as well as in prevention through risk management

The National Patient Safety Agency Established in 2001 Relates to England and Wales Responsible for National Reporting and Learning System (NRLS) Previously produced Patient Safety Alerts Now is developing systems of ‘Rapid Responses’ Produced guidance to the NHS on patient safety – ‘Seven Steps to Patient Safety’

Reported incidents by type (NPSA, April 2006 – March 2007)

Reported degree of harm

Seven Steps to Patient Safety

The Steps Step 7 - Solutions to reduce harm Step 6 - Learn and Share Lessons Step 5 - Patient involvement Step 4 - Promote Reporting and Learning Step 3 - Integrated Risk Management Step 2 - Lead and support your staff Step 1 - Build a Safety Culture that is open and fair

Step 1 - Build a Safety Culture that is Open and Fair Organisations, practices, teams and individuals have constant and active awareness of potential for things to go wrong Being open and fair means sharing information freely with patients and families balanced by fair treatment for staff when things go wrong Incidents are linked to the system in which an individual works

Safety Culture NPSA – A safety culture is where organisations, practices, teams and individuals have a constant and active awareness of the potential for things to go wrong. Both the individuals and the organisation are able to acknowledge mistakes, learn from them, and take action to put things right. Confederation of British Industry – The way we do things around here

Step 1 – Best Practice Don’t expect perfection from humans – use systems to support human decision making Establish reporting systems for errors and adverse events (practice; local; national) Assess your culture by undertaking a practice safety culture audit, eg MaPSaF

Step 2 - Lead and Support Staff Delivering patient safety needs motivation and commitment from clinical and managerial staff everyone has a responsibility for safety Leaders must be visible and active in leading patient safety improvements Staff and teams should be able to say if they do not feel that care is safe – regardless of their position Some ideas – patient safety champions; safety briefings; team briefings; safety walkabouts

Step 2 – Best practice Leadership – GPs and practice leaders have to own safety. Walk the walk Reflection – ‘How are we doing on safety?’ Training – Run in-house and seek out external provision Promotion – standing agenda item in clinical and business meetings

Step 3 – Integrate risk management activity Proactive Training in safety and risk Use risk assessment in major change management projects Review controls for minimising risk Reactive Incident reporting and analysis Significant event audit at team or unit level Root cause analysis at organisational level All of the above methods can be integrated

Step 3 – Best Practice Regular and embedded SEA in practice Sharing the learning from SEA Active and willing participation in other reactive methods, eg RCA Active participation in reporting systems ‘Should we report this?’ Embrace risk assessment methodology – identify and manage your risks

Step 4 – Promote reporting Reporting of patient safety incidents provides the opportunity to ensure that learning from what happened to one patient can reduce the risk of the same thing happening to another patient Reporting should be simple, timely, confidential (?anonymous), and have feedback mechanisms

Step 4 – Best Practice Report locally Learn and share locally Report nationally Involve patients and public in reporting and learning

Step 5 – Involve and communicate with patients and the public Patients’ expertise and experience can be used to identify risks and devise solutions to patient safety problems Staff need to include patients in identifying risks and in helping to protect themselves from harm Being open when things have gone wrong can help patients cope better afterwards

Step 5 – Best Practice Actively involve patients in safety culture and activity eg section on safety in annual reports, patient reps in risk assessments Seek patient views and comments Be open when things go wrong (‘Being open’ tool from NPSA available online)

Step 6 – Learn and share safety lessons Root cause analysis Intensive technique Usually for most serious incidents (deaths or multiple cases of harm) Normally at organisational level Requires trained facilitators Learning can be shared Significant Event Audit Developed in general practice and promoted by RCGP Team based Can link to conventional audit Can be themed Powerful driver for change Learning can be shared

Step 6 – Best Practice Regular structured SEA meetings Respond quickly when there are important events or when high risks are identified Involve patients Learn lessons and put learning into practice – don’t be doomed to see the same event happening over and over again

Step 7 – Implement solutions to prevent harm Design systems that make it easy for people to do the right thing and difficult for them to do the wrong thing Solutions that rely on physical barriers are far more effective than those that rely on human behaviour and action Solutions should be risk assessed, evaluated and sustainable in the long term

Step 7 – Best Practice Actively consider solutions in SEA meetings What have others done? What ideas can we get from staff and patients? Formal risk assessment of solutions Share your solutions with others

Where are we now? Increased awareness Enlistment of stakeholders Safety campaigns – 100,000 Lives in USA Leadership - ‘Safety First’, Dec 2006 Translating to action? What are they actually doing? WHO – Safer Surgery What is happening in New Zealand?

From ‘Seven steps’ to ‘Next steps’ Need safety culture to tackle safety problems, e.g. Infection control needs ALL Seven Steps Professional understanding and ownership – especially safety culture and human factors Work with safety professionals – a pilot or an engineer on every Healthcare Board? Research and evaluation to demonstrate clinical and financial benefits