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Lecture to 3rd year medical students on 15th
December 2013 at the Faculty of Medicine by Prof Omar
Hasan Kasule Sr. adapted from WHO Patient safety curriculum
LEARNING OBJECTIVES
·
To understand the discipline of
patient safety and its role in minimizing the incidence and impact of adverse
events
LEARNING
OUTCOMES: KNOWLEDGE
·
The harm caused by health-care
errors and system failures;
·
The lessons about error and
system failure from other industries;
·
The history of patient safety and
the origins of the blame culture;
·
The difference between system
failures, violations and errors;
·
A model of patient safety.
LEARNING OUTCOMES: PERFORMANCE
·
Apply patient safety thinking in
all clinical activities;
·
Demonstrate ability to recognize
the role of patient safety in safe health-care delivery.
KEYWORDS
·
Patient’s safety, system theory,
blame on culture, system failures, personal approach, violations and patient
safety models.
DEFINITION
OF PATIENT SAFETY
·
Patient safety is
defined as a discipline in the health-care sector that applies safety science
methods towards the goal of achieving a trustworthy system of health-care
delivery.
·
Patient safety is
also an attribute of health-care systems; it minimizes the incidence and impact
of, and maximizes recovery from adverse events
·
This definition
provides the scope for the conceptual model for patient safety.
WHY PATIENT SAFETY?
·
While health care has become more effective it has also become
more complex, with greater use of new technologies, medicines and treatments.
·
Health services treat older and sicker patients who often present
with significant co-morbidities requiring more and more difficult decisions as
to health care priorities.
·
Increasing economic pressure on health systems often leads to overloaded
health care environments
RELEVANCE OF PATIENT SAFETY
·
There is now
overwhelming evidence that significant numbers of patients are harmed from
their health care either resulting in permanent injury, increased length of
stay (LOS) in hospitals and even death.
·
adverse events occur
not because bad people intentionally hurt patients but rather that the system
of health care fails
EXAMPLES OF SAFETY ISSUES
·
Prescribing antibiotics
without regard for the patient’s underlying condition and whether antibiotics
will help the patient,
·
Administering multiple
drugs without attention to the potential for adverse drug reactions,
·
Poor communication
between different health-care providers
·
Delays in receiving
treatment.
·
Washing hands
correctly
·
Being a team player.
SIMPLE APPROACHES TO SAFETY
·
Engaging with
patients and their families,
·
Checking procedures
·
Learning from errors
·
Communicating
effectively with the health-care team: reporting and analysing errors
·
Understanding the
factors that lead to errors is essential for thinking about changes that will
prevent errors from being made.
THE
HARM CAUSED BY HEALTH-CARE ERRORS AND SYSTEM FAILURES
·
More than 2/3 of
adverse events are preventable: 28% negligence, 42% other factors
·
Medication harm to
patients 6.5/100 admissions in US teaching hospitals
·
In Australia medical
errors causes 18,000 deaths in a year and more than 50,000 disabled
·
In US medical error
caused 44,000-98,000 unnecessary deaths in a year
·
Other consequences of
errors: USD29b in hospitalization,
litigation costs, infections acquired in hospitals, lost income, disability and
medical expenses
PUBLISHED RESEARCH ON ADVERSE EVENTS
(RATE%)
·
United States (Harvard Medical Practice Study) 1984
3.8%
·
United States (Utah–Colorado
study) 1992 3.2%
·
United States (Utah–Colorado study) 1992 5.4%
·
Australia (Quality in
AustralianHealth Care Study) 1992 16.6%
·
Australia (Quality in Australian
Health Care Study 1992 10.6%
·
United Kingdom Acute care
hospitals 1999 11.7%
·
Denmark Acute care hospitals 1998
9.0%
SENTINEL EVENTS
(MOST SERIOUS ADVERSE EVENTS in the US
·
Suicide of inpatient
or within 72 hours of discharge 29%
·
Surgery on wrong
patient or body part 29%
·
Medication error
leading to death 3%
·
Rape/assault/homicide
in an in-patient setting 8%
·
Incompatible blood
transfusion 6%
·
Maternal death
(labour, delivery) 3%
·
Infant
abduction/wrong family discharge 1%
·
Retained instrument
after surgery 1%
·
Unanticipated death
of a full-term infant - N/A
·
Severe neonatal
hyperbilirubinaemia - N/A
·
Prolonged fluoroscopy
- N/A
·
Intravascular gas
embolism N/A -
N
HUMAN AND
ECONOMIC COSTS OF ADVERSE EVENTS…1
·
In South Australia the costs of
claims and premiums on insurance for large medical negligence suits to be about
AU$18 million in 1997–1998.
·
The National Health Service in
the United Kingdom pays out around £400 million in settlement of clinical negligence
claims every year
·
The US Agency for Healthcare
Research and Quality (AHRQ) reported in December 1999 that preventing medical
errors has the potential to save approximately US$ 8.8 billion per year.
HUMAN AND
ECONOMIC COSTS OF ADVERSE EVENTS…2
·
The Institute of Medicine report estimated
that between 44 000 and 98 000 people die each year from medical errors in hospitals
alone, thus making medical errors the eighth leading cause of death in the
United States.
·
The Institute of Medicine
estimated that preventable errors cost the nation about US$ 17 billion annually
in direct and indirect costs.
·
The human costs of pain, suffering,
loss of independence, loss of productivity (family and patient)
LESSONS ABOUT ERROR
AND SYSTEM FAILURE FROM OTHER INDUSTRIES..1
·
The large-scale technological
disasters in other industries led to development of systems and culture for
safety
·
The central principle was that
accidents are caused by multiple factors, not single factors in isolation: individual
situational factors, workplace conditions and latent organizational and
management decisions were commonly involved.
·
Analysis of these disasters also
showed that the more complex the organization, the greater potential for a
larger number of system errors in the organization or operation.
·
tracing the “chain of events” was
critical to an understanding of the underlying causes of accidents
LESSONS ABOUT
ERROR AND SYSTEM FAILURE FROM OTHER INDUSTRIES..1
·
latent human errors were more significant
than technical failures. Even when faulty equipment or components were present,
he observed that human action could have averted or mitigated the bad outcome.
·
In the Chernobyl catastrophe
organizational errors and violations of operating procedures due to poor safety
culture that tolerates violations of rules and procedures is critical.
·
Challenger crash investigation
showed how violations had become the rule rather than the exception.
·
only a systems approach (as
opposed to the more common “person” approach—of blaming an individual doctor or
nurse) will create a safer health-care culture because it is easier to change
the conditions people work in than change human actions.
HISTORY OF
PATIENT SAFETY AND THE ORIGINS OF THE BLAME CULTURE
·
Traditional management of failures
and mistakes in health care has been called the person approach—we single out
the individuals directly involved in the patient care at the time of the
incident and hold them accountable: the “blame culture”.
·
We identify the person—be they
medical student, nurse or doctor—who gave the wrong drug and blame him/her,
ashame him, discipline him, and retrain him
·
Policies change to tell the
individual how to avoid the error The focus is still on the individual staff members
rather than on how the system failed to protect the patient and prevent a wrong
medication being administered.
WHY
DO WE BLAME?...1
·
It is human nature to
want to blame someone and far more “satisfying” for everyone involved in investigating
an incident if there is someone to blame.
·
Attribution theory: The premise of this theory is that people
naturally want to make sense of the world, so when unexpected events happen, we
automatically start figuring out who caused it.
·
Pivotal to our need to blame is
the belief that punitive action sends a strong message to others that errors
are unacceptable and that those who make them will be punished.
WHY
DO WE BLAME?...2
·
The problem with the blame
culture is that it is predicated on a belief that the offender somehow chose to
make the error rather than adopt the correct procedure: that the person
intended to do the wrong thing.
·
Because individuals are trained
and/or have professional/organizational status, we think that they “should have
known better”
·
The prevailing cultural response
to mistakes, at that time, was to punish individuals rather than address any
system problems that may have contributed to the error(s).
·
Underpinning this practice was
the belief that, since individuals are trained to perform tasks, then a failure
of that task must relate to the failure of individual performance, thus deserving
punishment.
EXPLANATION OF
ERRORS
·
Human actions are
almost always constrained and governed by factors beyond an individual’s
immediate control.
·
People cannot easily
avoid those actions that they did not intend to perform.
·
Errors have multiple
causes: personal, task-related, situational and organizational factors.
·
Within a skilled,
experienced and largely well intentioned workforce, situations are more amenable
to improvement than people.
·
“hindsight
bias”—because most people involved in serious accidents do not intend something
to go wrong and generally do what seems like the “right” thing to do at the
time, though they “may be blind to the consequences of their actions”
·
Organizations that place a
premium on safety routinely examine all aspects of the system in the event of
an accident, including equipment design,
procedures, training and other organizational features
DIFFERENCE
BETWEEN SYSTEM FAILURES, VIOLATIONS AND ERRORS
·
Using a systems approach to
errors and failures in the system does not mean that system thinking implies a
“blame-free” culture.
·
individual health professionals
are required to be accountable for their actions and to maintain competence and
practise ethically.
·
Part of the difficulty is that
many health professionals daily break professional rules such as using proper hand
washing techniques, or letting junior and inexperienced providers work without proper
supervision.
·
Students may see doctors on the
wards or in the clinics who cut corners and think that it is the way things are
done.
TYPES OF
VIOLATIONS
·
Violation is a deviation from
safe operating procedures, standards or rules
·
Routine violation: Doctors who
fail to wash their hands in between patients because they feel they are too
busy.
·
Optimizing violation: Doctors who
let a medical student perform a procedure unsupervised because they are with their
private patients
·
Necessary violation: Nurses and
doctors who knowingly miss out important steps in medication dispensing because
of time constraints and the number of patients to be seen
A SYSTEMS
APPROACH TO VIOLATIONS
·
By applying systems thinking to
errors and failures, we can ensure that when such an event occurs we do not automatically
rush to blame the people closest to the error—those at the so called “sharp”
end of care.
·
Using a systems approach we can
examine the entire system of care to find out what happened rather than who did
it. Only after careful attention to the multiple factors associated with an
incident can there be an assessment as to whether any one person was responsible.
MODEL
OF PATIENT SAFETY: 4 MAIN DOMAINS
1.
Those who work in health care;
2. Those
who receive health care or have a stake in its availability;
3.
The infrastructure of systems for therapeutic interventions (health-care
delivery processes);
4.
The methods for feedback and continuous improvement.
FEATURES
OF THE SAFETY MODEL
• Understanding
the system of health care;
•
Recognizing that performance varies across services;
•
The methods for improvement including how to implement and measure
a change;
•
Understanding the people who work in the system and their
relationships with one another and the organization.
STUDENT
APPLICATION OF PATIENT SAFETY THINKING
·
Relationships with
patients: Relate and communicate with each individual
·
patient as a unique
human
·
Understand the
multiple factors involved in failures
·
Avoid blaming when an error
occurs
·
Practice evidence-based care
·
Maintain continuity of care for
patients
·
Awareness of the importance of self-care
·
Act ethically everyday