1

2

Patient Safety:

Understanding Human Error in Healthcare

3

Aims

• To develop the knowledge, skills and attitudes that promote: – the reduction of medical error to improve

patient safety– learning from error in healthcare to improve

patient safety

4

Learning Outcomes

• Knowledge

– What is a medical error?– How and when does this happen?– How do people make errors?– Why do people make errors?– What happens when an error is made?– How do people feel when they make errors?

5

Learning Outcomes

• Skills– Recognition of error– Dealing with error– Reporting and learning from error– Supporting others involved in error

6

Learning Outcomes

• Attitudes– Focuses on cause rather than culprit– Willing to learn from mistakes– Being prepared to acknowledge and deal with error– Being prepared to reflect on practice– Trust and respect

7

Introduction and Background

Human Error- “We cannot change the human condition, but we can change the conditions under which humans work”.

(James Reason BMJ March 2000)

8

Personal vs System Approach

• Personal approach – focuses on the unsafe acts– “sharp end”- name and shame

• System approach– errors seen as consequence not cause– aim to build defences and safeguards

• Health care – now learning from other industries• High technology systems have many defensive layers -

like a Swiss cheese• Active failures• Latent conditions

Reason BMJ March 2000

9

Defencesin depth

Other 'holes'due to latent

conditions

Some 'holes'due to active

failures

DANGER

From Reason 1997

10

Definitions

• Adverse patient incident - any event or circumstance arising during NHS care that could have or did lead to unintended or unexpected harm, loss or damage.

• Harm - injury (physical or psychological), disease, suffering, disability or death.

• Incidents that lead to harm- Adverse Events.• Incidents that do not lead to harm - Near Misses.• Other terms which may be used - clinical incident, critical

incident, serious untoward event, significant event(National Patient Safety Agency 2001)

11

What is happening? – the world

• Australia – Australian Patient Safety Foundation – established as an association 1989

• USA – National Patient Safety Foundation – established 1998

• Canada – Canadian Patient Safety Institute established 2003

• WHO – World Alliance for Patient Safety launched 2004

12

What is happening? - UK

• High profile reports of errors leading to patient morbidity and mortality e.g. Bristol

• 2000 - Department of Health publish - “An Organisation with a Memory”

• 2001 - National Patient Safety Agency established in England

• to improve safety of patients by promoting a culture of reporting and learning from patient safety incidents

13

National Patient Safety Agency

• The National Reporting and Learning System on patient safety incidents

• Aims:– To identify trends and patterns and underlying causes– To develop models of good practice at national level– To improve working practice by feedback and learning

– To encourage education and training (NPSA: Seven steps to patient safety, Nov

2003)

14

Discussion

• If people try hard enough they will not make any errors

• If we punish people when they make errors, they will make fewer of them

15

Extent and Nature of Adverse Events in Healthcare

• 850,000 adverse events per year (NHS)• 44,000 incidents fatal• Half are preventable• Accounts for 10% of admissions• Costs the service an estimated £2 billion per

year (additional hospital stays alone, not taking into account human or wider economic costs e.g. litigation)

16

Factors Contributing to Human Error

• Environmental Factors– Light– Noise and Vibration- Alarms!– Temperature– Humidity– Restrictive/ protective clothing– Equipment layout and design– Physical environment

17

Factors Contributing to Human Error

• Some examples of personal factors– Fatigue– Stress– Workload– Distraction– Drugs/ Alcohol– Hypoglycaemia– Hypovolaemia

18

Professional Cultural Issues Underlying Error

• A definition of culture

– “how we do things around here”

19

Reporting Systems

• Some National Examples– Scottish Audit of Surgical Mortality– National Confidential Enquiry into Patient Outcome and Death– Why Mothers Die: Report on Confidential Enquires into Maternal

Deaths in the UK– The Confidential Enquiry into Stillbirths and Deaths in Infancy– Yellow Card - BNF– Royal College of Anaesthetists - Critical Incident Reporting– Scottish Confidential Audit of Severe Maternal Morbidity

• Some Local examples– OR1 forms / Medication Error reporting forms– Significant Event Analysis in General Practice– Risk management and M&M meetings– Paediatric Surgical error Book

20

Factors Contributing to Successful Error Reporting

• Culture - just, reporting, flexible, learning

• Treats less experienced staff as professionals

• Accept human fallibility – even good doctors!

• Training on safety issues• Annual appraisal• Ground rules established

- acceptable and unacceptable behaviour

• Support / trust / leadership

• Well run - good input and change implemented with good communication

• Consistency• Clear instructions• Anonymity• Confidential• Voluntary

21

Barriers to Successful Reporting

• Fear of individual / organisational repercussion• Defining reportable errors too narrowly• Length of contract / time in job• Workload involved - usually time (form filling)• Culture of fear of “losing an otherwise good nurse /

doctor”• Where reporting has not brought about change• Uncertainty right and wrong - differing opinions

22

Disclosure

• What does it feel like?• What needs to be done?

– Write it all down– Document in the patient’s notes– Tell your consultant– Local reporting system– Write to GP?– Tell the defence union– COMMUNICATE! Patient and their relatives

23

Communication

• Needs to be handled carefully- all parties in highly charged emotional state

• Relatives- distressed / anxious / angry• Health workers- panic / guilt / uncertainty / anxiety• CALM• Enlist help of colleague• Statement of situation and apology• Bad news given - recipients should be offered privacy, access

to phones, offers to call family / friend• Organise future meeting

from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

24

Meeting with Relatives/ Patients

• Ensure all facts are collected and available• If patients have special needs- arrange interpreters• Mutually convenient time• Comfortable environment- no interruptions eg staff /

phones / bleeps• Introduce yourself clearly• Establish who is present and why• Explain how the meeting will progress

from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

25

Meeting

• Explain facts in clear, jargon - free language• Identify unresolved issues and ensure these are being

investigated further• Patients current condition and probable outcome should

be described honestly• Check on understanding

from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

26

Language

• Try not to attribute blame unless clear cause• Express regret - “We are extremely sorry that your…”• Avoid comments like “ I can understand how upset you

must be”• Rather “In similar circumstances I think most people would

feel as you do now, but I can assure you that we want to help you to deal with it”

• Person apologising on behalf of the organisation - impartial(?)

• Be prepared for a variety of emotional reactions

from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

27

Plan• Outline what treatment plan is now being undertaken• Reassure that all possible measures are being taken to resolve

harm done• Explain what is being done to prevent same thing happening again• Arrange further meeting if appropriate• Offer a break?• Procedures for compensation• Emotional support• Details about full inquiry• CONCLUSION

from ‘Confronting errors in patient care’ Firth-Cozens, Redfern & Moss

28

Support Systems

• Your colleagues!• Doctors Plus

– See patient safety website for details

• Sick Doctors Trust – For doctors who are suffering from addiction– www.sick-doctors-trust.co.uk/

• A Framework of Support– GMC– National Counselling Service for Sick Doctors– The British Doctors and Dentists Group– BMA Stress Counselling Service