Clinical Safety & Systems

Improvement

Dr N Maran FRCA FRCSEd

AMD for Patient Safety NHS

Lothian

1

Quality addresses the intended results of a system

– safety,

– efficiency,

– effectivenesss,

– equity,

– timeliness &

– patient (& staff) experience

2

Patient Safety

“The avoidance, prevention and amelioration of

adverse outcomes or injuries stemming from

the process of healthcare”

Vincent 2010

Recognising harm in healthcare

• 20% of patients experienced 1 or more untoward episodes

• 10% had prolonged or unresolved episode

Schimmel Ann Int Med 1964

• Estimated as many as

44,000 to 98,000 deaths each year in USA

• More than motor vehicle accidents, breast cancer and AIDS combined annually

“To Err is Human”, Institute of Medicine, 1999*

Global impact of harm in healthcare High Income Countries

• Acute hospitals adverse event rate 3-36% – 30-50% preventable

• Primary care 9% of records indicate error

• Community hospitals adverse event rate 15%

Low & Middle Income countries

• 8-10% patients receiving hospital care

• 83% preventable

• 30% led to death

• 2/3 of all adverse events globally

WHO 2016 Health Foundation 2011

What do we mean by harm? • Treatment specific harm

• Harm due to over treatment

• General harm from healthcare

• Harm due to failure to provide appropriate treatment

• Harm due to failed or inadequate diagnosis

• Psychological harm and feeling unsafe

• Harm due to neglect and dehumanisation

Consequences of Patient Safety

Incidents • Nothing / minor

inconvenience

• Prolonged hospital stay

• Readmission

• Delayed / missed diagnosis

• Disability

• Chronic pain

• Incontinence

• Psychological trauma

• loss of independence

• loss of earnings

• Death

Understanding harm

Adverse event review

• Critical Incident reporting / review

• Significant adverse event review

• Incident / speciality specific review

• Morbidity and mortality review

Systematic review

• Structured chart review – Mortality review

– Adverse event review

Datix reporting NHSLothian 2017-19

Events associated with major harm and death 2017-19

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

50

100

150

200

250

300

350

400

No

of

SAE'

s

Category

NHS Lothian Adverse Events Reported with Major Harm of Death 01/04/17-31/03/19*

Total Cumulative % * only displays top 21 categories

Patient Safety Incidents

• Omissions / Prescribing / preparation

• Medrec / ADEs / high risk meds Medication incidents

• MRSA / C.Diff / SAB Antimicrobials

• Indwelling devices – PVC / CVC / CRI Hospital Acquired infection

• SSI Technical misadventure

• Wrong patient / procedure / site Procedural adverse events

• Accuracy , timing

• Failure to recognize deterioration / sepsis / CTG Diagnostic errors

• Falls Functional decline

• Pressure ulcers Delirium Care based harms

• Poor teamwork

• Lack of information flow / poor handover Communication errors

harm is more often the result of lack of diligence in performing ordinary tasks rather than a lack

of extraordinary skills

The Scottish Patient Safety Programme

SPSP Acute Care

WHAT By January 2013

• 15 % reduction in Standardised Mortality Rate (HSMR) in hospitals in hospitals across Scotland

• 30% reduction in Adverse Events (GTT)

• 30% reduction in cardiac arrests

HOW

• Evidence based interventions

• Data measurement

• Quality improvement methodology

Scottish Patient Safety

Program

Work Area Change Package Element Critical Care Establish infrastructure

–Daily goal sheets

–Daily multi-disciplinary rounds

Infection Prevention

–Ventilator bundle

–Central line bundle

General Ward Risk Identification and Response

–Rapid response (Outreach) teams

–Early warning system

Infection Prevention -MRSA

Reliable care for Congestive heart failure

Communication and Teamwork

–Safety briefings

–Communication tools (e.g. SBAR)

–Prevention pressure ulcers

Leadership Infrastructure to support safety

Walkrounds

Safety a strategic priority

Medicines Management “Reconciliation”

Anticoagulation , Insulin,

Conduct an FMEA on a high risk medication process

Perioperative DVT Prophylaxis

Beta blockade

SSI bundle

Team culture - briefings

Sustainable universal implementation with high levels of reliability

What can we do? • Safe Prescribing / medrec

• Preparation / Administration Medication errors

• Hand hygiene

• PVC insertion & maintenance Hospital Acquired infection

• Checklists, skills training

• Antibiotic use Procedural adverse events

• Differential diagnosis / Regular review

• Early recognition of deterioration Diagnostic errors

• Clarify information / clear plans

• Clear recording / complete / legible Documentation errors

• Teamwork / safety briefs

• Handover / closed loop communication Communication errors

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

Jan

-09

Ap

r-0

9

Jul-

09

Oct

-09

Jan

-10

Ap

r-1

0

Jul-

10

Oct

-10

Jan

-11

Ap

r-1

1

Jul-

11

Oct

-11

Jan

-12

Ap

r-1

2

Jul-

12

Oct

-12

Jan

-13

Ap

r-1

3

Jul-

13

Oct

-13

Jan

-14

Ap

r-1

4

Jul-

14

Oct

-14

Jan

-15

Ap

r-1

5

Jul-

15

Oct

-15

Jan

-16

Ap

r-1

6

Jul-

16

Oct

-16

Jan

-17

Ap

r-1

7

Jul-

17

Oct

-17

Jan

-18

Ap

r-1

8

Jul-

18

Oct

-18

Jan

-19

Rat

e p

er

10

00

Dis

char

ges

Cardiac Arrest Rate per 1000 Discharges NHS Lothian (RIE, WGH, SJH *Liberton included until Jun '17)

(excludes A&E, ITU, CCU, Daycase, Reason for Admission = Out-Patient, Obstetric)

Baseline median (12 months) = 1.9117% reduction in CA rate from January '13. 12 month median = 1.58

Target Median = 50%

Increase noted from May 16. Median is now 1.76 (8% reduction from baseline)

Sustainedimprovement noted from Apr '18. Revised 12 month median = 1.07 (44% reduction from baseline)

Cardiac arrest rate NHS Lothian

Learning from deteriorating patient reviews

• Anticipatory planning commonest contributor

• NEWS scoring generally accurate

• Initial escalation reliable

• Initial management of deterioration good

• Frequency of obs for high NEWS poor

• Review unreliable

• Re-escalation difficult

Hospital Acquired Infection

C Diff

22

Simulation in systems

• Safe environment to learn & rehearse new skills

• Training for low frequency / high impact events

• Testing new processes

• Testing new equipment

• Testing / design of work spaces

• Systems testing / major incident drills

• Faculty role modeling

• Supporting / developing a culture of safety

Patient safety - opportunities

• Local improvement work

• Quality improvement teams (QIT)

• Cardiac arrest / deteriorating patient work

• Mortality reviews

• SAE reviews

• Simulation faculty

24

QI opportunities & resources

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• Lothian Quality Academy

• NES Quality Improvement courses

• SPSQ fellowships

Questions?