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

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

3. Policy
Theory

4. 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
Beyond

5. 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
May 2010

6. >60% preventable 28% negligence ‘this was not my fault’
Leape L et al. Preventing medical injury. Quality Review Bulletin, 1993,8:

8. We all make mistakes !

10. 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.

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

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

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

15. 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

16. 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

17. 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)

18. 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

19. 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

21. Clinical Governance Strategy 2013 – 2016
Adverse event management

22. Copies available

24. 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?

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