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Presentation to 3rd Year
Medical students at the Faculty of Medicine King Fahad Medical City Riyadh on
May 27, 2013 by Professor Omar Hasan Kasule Sr.
Keywords: Clinical risk,
reporting near misses, reporting errors, risk assessment, incident, incident
monitoring.
Learning
objective: Know
how to apply risk management principles by identifying, assessing and
reporting hazards and potential risks in the workplace.
Why clinical
risk is relevant to patient safety
·
Risk management is routine in
most industries
·
The success of a risk management
programme depends on the creating and maintaining safe systems of care
·
Many hospitals have well
established systems in place for reporting adverse events. They are only
beginning to focus on all aspects of clinical care to see opportunities for
reducing risks to patients.
·
Unfortunately, even though a
hospital may have a policy of reporting incidents such as medication errors,
the actual reporting of them is often sporadic.
·
Research shows that nurses are
more likely to report an incident than other health professionals, certainly
more so than doctors. This may be because the blame culture in medicine is a
strong deterrent to reporting.
Concern of
clinical risk management
·
Clinical risk management
specifically is concerned with improving the quality and safety of healthcare
by identifying the circumstances and opportunities that put patients at risk of
harm and then acting to prevent or control those risks.
·
The following simple four-step
process is commonly used to manage clinical risks: 1. identify the risk; 2, assess
the frequency and severity of the risk; 3. reduce or eliminate the risk; 4. assess
the costs saved by reducing the risk or the costs if the risk eventuates.
·
Clinical risk management allows
identification potential errors. Health
care itself is inherently risky and although it would be impossible to eradicate
all harm, there are many activities and actions that can be introduced that will
minimize opportunities for errors.
·
Clinical risk is relevant to
medical students because it recognizes that clinical care and treatment are risky
and incidents may to occur during clinical care and treatment.
·
Health-care professionals) must
actively weigh up the anticipated risks and the benefits of each clinical
situation and only then take action.
Root cause
analysis
·
The principle underpinning root
cause analysis is that the actual (root) cause of a particular problem is
rarely (immediately) recognizable at the time of the mistake or incident.
·
A superficial and biased assessment
of any problem usually does not fix the problem and more incidents will occur involving
others in similar situations.
·
An essential part of any root
cause analysis is the implementation of the findings of the root cause analysis
process.
·
Many hospitals and organizations
fail to complete the process because either the recommendations involve resources
that are not available or there is no commitment by the senior hospital management
to carry through the recommendations.
·
Some health-care organizations
that mandate reporting of incidents can become so overloaded with reported
incidents with the consequence that many remain unanalysed due to inadequate resources.
·
Even the introduction of a triage
system to distinguish serious incidents from others has not resolved this
dilemma in some systems.
Common
activities used to manage clinical risk.
·
Incident monitoring:
communication, decision making
·
Sentinel events: A sentinel event
is an unexpected occurrence involving death or serious physical or psychological
injury
·
Complaints in improving care
a More than one
type of incident may be assigned to a report.
Coronial
Investigations
·
Most countries have some system
for establishing cause of death.
·
Specifically appointed people, often
called coroners, are responsible for investigating deaths in situations where
the cause of death is uncertain, or thought to be due to unethical or illegal
activity.
·
Coroners often have broader powers
than a court of law and after reporting the facts will make recommendations for
addressing any system-wide problems.
Fitness-to-practise
requirements
·
Medical students and all health
professionals are accountable for their actions and conduct in the clinical
environment. Related to accountability is the concept of “fitness to practise”.
·
Many mistakes leading to adverse
events are associated with the fitness of a doctor to practise. Are they competent?
Are they practising beyond their level of experience and skill? Are they
unwell, suffering from a stress or a mental illness?
·
Most countries will have a system
for registering doctors, dealing with complaints and maintaining standards.
·
Selecting the right students to
study medicine is the first step in making sure that the people who are choosing
medicine as a career have the professional attributes for safe and ethical practice.
·
Objective Structured Clinical
Examination processes to help identify those students who in addition to their
examination results also have the attitudes and behaviours best suited to
medicine and patient safety.
Credentialling
·
Credentialling is the process of
assessing and conferring approval on a person’s suitability to provide specific
consumer/patient care and treatment services, within defined limits, based on an
individual’s license, education, training, experience and competence
·
Many hospitals have credentialing
processes in place to check whether a doctor has the required skills and
knowledge to undertake specific procedures or treatments.
·
Hospitals will restrict the type
of procedures offered at a hospital if there are no qualified personnel or if the
resources are not available or appropriate for the particular condition or
treatment.
Accreditation
·
Accreditation is a formal process
to ensure delivery of safe, high-quality health care based on standards and processes
devised and developed by health-care professionals for health-care services.
·
It can also refer to public
recognition of achievement by a health-care organization of requirements of
national health care standards.
·
CBAHI & JCI
Registration
·
Most countries require medical
practitioners to be registered with a government authority or under a government
instrument.
·
The principal purpose of a registration
authority is to protect the health and safety of the public by providing
mechanisms designed to ensure that medical practitioners are fit to practice
medicine.
·
It achieves this by ensuring that
only properly trained doctors are registered, and that registered doctors
maintain proper standards of conduct and competence.
The role of
fatigue and fitness to practise
•
There is strong scientific
evidence linking fatigue and performance.
•
Studies in the Ireland and the
United Kingdom also show that fatigue can impact on the well-being of residents
affecting their mood (depression, anxiety, anger and confusion)
•
Recent controlled studies have
confirmed the findings that sleep deprivation can negatively impact on clinical
performance
•
Fatigue has also been linked to
increased risk of medical errors and motor vehicle
•
accidents;
•
A 2004 study by Landrigan et al.
was one of the first to measure the effects of sleep deprivation on medical
errors. They found that interns working in the medical intensive unit and coronary
care unit made substantially more serious mistakes when they worked frequent
shifts of 24 hours or more than when they worked shorter shifts.
•
Other studies show that sleep deprivation
can have similar symptoms to alcohol intoxication
Stress and
mental health problems
•
Strong evidence suggests
physicians are prone to mental health problems, particularly depression,
Students also suffer from stress and associated health problems that they carry
with them when they start practicing as doctors;
•
While rates of depression and
mental health problems among doctors are higher than those experienced by the
general population, the literature shows that when interns and residents are
supported by fellow house officers and senior clinicians, and are members of
well-functioning teams, they are less likely to feel isolated and suffer
stress;
•
Performance is also affected by
stress;
•
There is strong evidence
indicating that inadequate sleep contributes to stress and depression, rather
than the number of hours worked;
•
Other stressors identified in the
literature include financial status, educational debt and term allocation and
emotional pressures caused by demands from patients, time pressures and
interference with social life.
Work environment
and organization
•
Hospitals and clinics can be very
stressful places to the newcomer. Unfamiliar work practices and rosters can
make it very difficult in the early phase of a new workplace. In addition, long
hours cause fatigue.
•
There are well-known situations such
as changeovers of shift, shift work, nights, week ends and overtime that have
been noted to have an association with increased errors.
•
The factors underpinning these
errors can range from lack of supervision to tiredness. Students should be
extra vigilant during these times.
Supervision
•
Good supervision is essential for
every student and the quality of the supervision will determine to a large extent
how successfully a student integrates and adjusts to the hospital or clinical environment.
•
The failure of senior clinicians
to supervise or arrange adequate supervision for medical students and interns
and residents makes them more vulnerable to making mistakes either by omission
(failing to do something) or commission (doing the wrong thing).
•
Students should always request
supervision if it is the first time they are attempting a skill or procedure on
a patient. They should also advise the patient that they are students and request
their permission to proceed to treat them or perform the procedure.
•
Poor interpersonal relationships
between students, other health-care professionals, interns, residents and
supervisors have also been identified as factors in errors. If a student is
having a problem with a supervisor, they should seek help from another faculty member
who may be able to meditate or help the student with techniques to improve the relationship.
•
The literature also shows that
students who have problems with inadequate skills acquisition also have poor
supervision.
Communication
Topics
•
Communicating accurate
information in a timely way between the multiple health workers (consultants, registrars,
nurses, pharmacists, radiologists, medical records and laboratory personnel) is
not easy, nor are there standard ways for communicating within hospitals.
•
The role of good communication in
the provision of quality health care and the role poor communication plays in
substandard care are both well documented.
•
How successfully patients are
treated will often depend on informal communications among staff and their
understanding of the workplace. Treatment errors caused by miscommunication,
•
Absent or inadequate communications
are well known and occur daily in hospitals.
•
The quality of the communication
between patients and other health professionals strongly correlates with
treatment outcomes.
•
Checklists, protocols and “care
pathways” are effective for communicating patient care orders.
What students
need to do (performance requirements)
·
Know how to report known risks or
hazards in the workplace
·
Keep accurate and complete
medical records
·
Know when and how to ask for help
from a supervisor, senior clinician or
·
other health professional
·
Participate in meetings that
discuss risk management and patient safety
·
Respond appropriately to patients
and families after an adverse event
·
Respond appropriately to
complaints
Summary of the
session
·
Doctors are responsible for the
clinical outcomes of their patients.
·
One way for doctors to manage
this is to identify areas prone to errors and adverse events.
·
The proactive intervention of a
systems approach to minimizing the opportunities for errors can prevent adverse
events.
·
Individuals can also maintain a
safe clinical working environment by looking after their
·
own health and responding
appropriately to concerns from patients and colleagues.
Case #1: Inadequacy
in orthopaedic surgeon’s practice management systems
Accurate and legible
records are essential for maintaining continuity of care.
Brian was being treated
by a new specialist and needed his records from the orthopaedic surgeon who
operated on his knee two years earlier. When the records finally arrived,
Brian’s new doctor informed him that they were not “up to scratch”. The
records were poorly documented with no meaningful notes concerning the
consent discussion for Brian’s operation. There were also gaps in the
information recorded in the operation report and there was no documentation of
the orthopaedic surgeon’s verbal advice about the risks and
complications of the operation. Brian was dismayed to discover that the
surgeon had not followed up on a missed postoperative review.
Case #2:
Acknowledgment of medical error: This case shows the value of open
disclosure.
Frank is a
resident of an aged care facility. One night, a nurse mistakenly gave Frank
insulin, even though he does not have diabetes. The nurse immediately recognized
his error and brought it the attention of the other staff, who in turn informed
Frank and his family. The facility took immediate action to help Frank and
arranged his transfer to a hospital where he was admitted and observed before being
returned to the aged care facility. The nurse was commended for fully and immediately
disclosing the incorrect administration of the insulin. Following this
incident, the nurse undertook further training in medications to minimize the
possibility of a similar error occurring.
Case #3: General
practice rooms not up to standard: this case shows the importance of
complaints to
improving
health care.
When Denise visited
her local medical practice, she was shocked to see that the practice was not as
hygienic as she expected. It was so bad that she complained to the New South
Wales Department of Health. A health inspector noted that Dettol was stored in
a drink container, drugs were stored beyond their use-by date, there was no
adrenaline in the surgery to treat a heart attack, patients at times had
unsupervised access to the doctor’s medical bag containing injectable narcotics
and a prescription pad, paper sheets on the examination table were not changed
between patients and the doctor did not wash his hands following examinations.
There were also no sinks in the consulting rooms. The Health Care Complaints
Commission recommended counseling by the New South Wales Medical Board and an
on-site visit to advise the staff on Department of Health guidelines on infection
control and make sure the appropriate steps had been taken to protect public
health. Denise was glad to learn that the centre made improvements as a result
of her complaint.
Case #4: Inadequate
complaints management This case shows the importance of timely attention to
complaints.
Alexandra had
been seeing a psychologist who was practising in a private hospital. On both
her first and second consultations, the psychologist breached patient
confidentiality by discussing personal details about his other patients. Alexandra
decided she should raise her concerns with someone at the hospital. She
attended one meeting with hospital representatives about a number of concerns
she had with the hospital, including those with the psychologist. Many months
passed with no written response from the hospital detailing the actions they
had promised to take. With the help of the Patient Support Office, Alexandra
attended a meeting with an official of the office and the chief executive
officer and deputy chief executive officer of the hospital. The hospital made
an apology to Alexandra and a commitment to ongoing staff training in complaints
management. They also encouraged Alexandra to lodge a formal complaint with the
Psychologists Registration Board regarding the psychologist’s behaviour.
Case #5: An
impaired nurse:
This case shows how health professionals need to maintain their fitness to practice.
During Alan’s
operation, a nurse knowingly replaced the painkiller fentanyl, which was
ordered to treat Alan, with water. This nurse placed Alan in physical jeopardy
because of the nurse's desperate need to obtain an opiate drug to satisfy his
drug addiction. This was not the first time that the nurse had stolen Schedule
8 drugs for the purposes of self administering them. A number of complaints had
been made about the nurse while working at a
Case #6: A junior
doctor with bipolar disorder The case shows how important it is to
refer
colleagues
who are unwell and to protect patients from clinicians who behave unethically.
Irene was upset because
her new doctor verbally abused her during the consultation at the hospital clinic.
She asked for another doctor and made a complaint to the hospital
administration. Irene’s complaint was just one of a number of complaints against
the doctor including others concerning a refusal to treat a patient, making sexual advances to staff and patients and neglecting his own diabetes
condition. He also refused to comply with psychiatric treatment suggestions.
One year earlier, the doctor had been investigated for prescribing errors and
sexual advances to patients. At that time, the doctor was reviewed and diagnosed
with a long-standing bipolar (manic depressive) disorder. He had made undertakings
in relation to treatment of his mental illness, which he was obviously not
observing now.