bowtie in healthcare - hu-tech

Hu-Tech Human Factors 18-4-2017

CGE Risk Management 1

Copyright © 2012 IP Bank BVCopyright © 2012 IP Bank BV

BowTie in Healthcare

How to use the visual and qualitative BowTie risk assessment method forAccreditation, Compliance, Quality Management and Patient Safety

Copyright © 2012 IP Bank BV

Introduction

The leading provider of barrier based risk management software solutions for assessing and managing risks at an enterprise level.

Market leader in oil & gas, chemicals, aviation,mining, transport, healthcare, maritime, utilities…

Started in 2004

With 20-30% annual growth in the last 6 years

1800+ clients in 83 countries

200+ partners around the world

Knowledge sharing: involved in 80-90 events per annum




Some of our customers


History of BowTie

1979

1988

90’s

00’s

10’s

Risico Inschatting

Barrier Management




BowTie – a visual and “qualitative”method to assess risks


Barrier Management

Barrier Management is a way to look at your normal operations from a risk perspective using the bowtie method.

and to manage critical “barriers” using existing data to see if you are “ALARP” (As Low As Reasonably Practicable”) and safe to operate.

This means:Being in control of your normal operations = working more efficient = working more safe = comply to rules and regulations = better quality = prevent incidents and accidents = minimize Non Production Time




Barrier Management

Uncontrolled release of

hydrocarbon

s at surface

from test

equipment

P.01

Hydrocarbons

during well testing

Manual shut in at

well test choke

manifold

Flare booms are under continual

surveillance / fire

watch

Continual pilot light

Test of ignition

system prior to

well test

Flame failure at

flare booms

(flare out)

Ongoing thickness checks of lines and

vessels

Sand detectorsWell testing equipment is

pressure tested

Corrosion / Erosion of well

test equipment

Continuous

monitoring of pressure gauges

Well testing

equipment is pressure tested

Conduct pre-well

testing Risk

Assessment, HAZID and audit

Pressure vessel failure

Valve state communicated by

the flow head

alignment board

Valve operation

recorded the flow

head alignment log

Opening

incorrect valve

on well testing equipment

Implementation of

SOPEP

Implementation of

offshore

emergency

response plans

Hydrocarbon

liquids discharged into

ocean

Emergency

respiratory

equipment

Automatic Deluge

System

Adequate

ventilation

Inhalation of

toxic gas

Ignition controlAutomatic Deluge

SystemEvacuation plan Life Rafts

Fire / Explosion

Understanding your core processes froma risk perspective:

What can cause disruptions?

Using a method(‘BowTie’) that hasbeen used for many years in a numberof hazardous industries


The BowTie, named after its shape, contains eight elements: hazard, top event, threats, consequences, preventive barriers, recovery barriers, escalation factors and escalation factor barriers

The BowTie method




A picture says more than a thousand words

Ba rri er Na m e

Apply wristband upon admission to the ward

(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong patient // (Br.) Apply wris tband upon admiss ion to the ward Apply wris tband upon admission to the

ward

At admiss ion on the ward: Check the patient's identity by nurse together with patient through open questions

(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong patient // (Br.) At admission on the ward: Check the patient's identity by nurse

together with patient through open questions

At admission on the ward: Check the

patient's identity by nurse together with

patient through open questions

At preoperative screening: Check the anethes ia tecnique by anesthes iologis t together with patient in accordance with the planned procedure

(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong anethesia technique // (Br.) At preoperative screening: Check the anethesia

tecnique by anesthesiologist together with patient in accordance with the planned procedure

At preoperative screening: Check the

anethes ia tecnique by anesthes iologis t

together with patient in accordance with

the planned procedure

At preoperative screening: Check the diagnosis and procedure by anesthesiologist together with patient twith electronic medical record

(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong procedure // (Br.) At preoperative screening: Check the diagnos is and procedure by

anesthesiologist together with patient twith elec tronic medical record


diagnosis and procedure by

anesthesiologist together with patient

twith electronic medical record

At preoperative screening: Check the operating s ite and s ide by anesthesiologist together with patient twith elec tronic medical record

(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong site /side // (Br.) At preoperative screening: Check the operating s ite and side by

anesthesiologist together with patient twith elec tronic medical record


operating site and s ide by

anesthesiologist together with patient

twith electronic medical record

At preoperative screening: Check the patient's identity by anesthes iologis t together with patient through open questions

(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong patient // (Br.) At preoperative screening: Check the patient's identity by

anesthesiologist together with patient through open questions


patient's identity by anesthesiologist

together with patient through open

questions

At surgery preparation room, check perioperative marking and completeness elecronic medical record by nurse and s taff member with awake patient

(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong procedure // (Br.) At surgery preparation room, check perioperative mark ing and

completeness elecronic medical record by nurse and s taff member with awake patient

At surgery preparation room, check

perioperative marking and

completeness elecronic medical record

by nurse and staff member with awake

patient

(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong site /side // (Br.) At surgery preparation room, check perioperative mark ing and

completeness elecronic medical record by nurse and s taff member with awake patient

At surgery preparation room, check

perioperative marking and

completeness elecronic medical record

by nurse and staff member with awake

patient

At surgery preparation room, check the patient's identity by anesthes iologis t and staff member with awake patient through open questions

(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong patient // (Br.) At surgery preparation room, check the patient's identity by

anesthesiologist and s taff member with awake patient through open questions

At surgery preparation room, check the

patient's identity by anesthesiologist

and staff member with awake patient

through open questions

At surgery preparation room, check the patient's identity by nurse and staff member with awake patient through open questions

(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong patient // (Br.) At surgery preparation room, check the patient's identity by nurse and

staff member with awake patient through open questions

At surgery preparation room, check the

patient's identity by nurse and staff

member with awake patient through

open questions

At the s tart of the surgey the surgeon, anaesthesiologist, operating assistant and nurse anesthetist and awake patient - check on the basis of the elec tronic medical

record / - whether it is the: right patient; right site and s ide; appropriate intervention; adequate supplies

(Haz.) Operating a patient / Applying incorrec t procedure // (Tht.) Wrong anethesia technique // (Br.) At the start of the surgey the surgeon, anaesthes iologis t,

operating assistant and nurse anesthetist and awake patient - check on the bas is of the elec tronic medical record / - whether it is the: right patient; right site and

side; appropriate intervention; adequate supplies

At the start of the surgey the surgeon,

anaesthesiologist, operating ass istant

and nurse anesthetist and awake patient

- check on the basis of the electronic

medical record / - whether it is the: right

patient; right site and side; appropriate

intervention; adequate supplies


Risk Analysis

Do you have enough barriers?

?




Understand interdependencies

What if the Engineering Manager...?

! ! !


The Essence

Being in control of “what you do” is about being able to answer 3 basic questions:

1. Do we understand what can go wrong?

2. Do we know what our systems are to prevent this happening?

3. Do we have information to assure us they are working effectively?




Understand

Know

Assure

What barriers are needed?

Are they there in place?

Audit

Learning from Incidents

Performance Indicators

Management System Data

Hazards, Top Events,

Threats & ConsequencesLosing

control over the vehicle

H01.0 Driving a vehicle

Intoxicated driving

Slippery road conditions

Poor visibility (external)

Crash into other vehicle or

motionless object

Hitting a pedestrian/

cyclist

Vehicle roll-over

D4 D2 D0 D1

C4 C1 C0 C2

C4 C2 C0 C1


And use existing data ‘smarter’

Risk Based Audits




Learning from incidents

Improvement actions


Why Bowties in Healthcare?

Get insight+ oversight of complex scenarios

Identification of weak spots, opportunities to improve and opportunities to make better use of resources / save time and money

For structure thinking

For risk based decision making

For communication & training

For monitoring the status of barriers

BowTie can be used in healthcare organizations such as hospitals to perform risk assessments. Bowtie has multiple advantages as a method for proactive risk analysis, for example the visual character or the diagram is ideal for risk communication.




For who?

Executive Management

Patients/Families

Regulators/JCI/UK healthcare ST.

Patient Safety Specialists

Operations mangers

Quality Managers

Supervisors

Medical Teams

Supporting Functions/Facility


Why would you try to understand yourprocesses from a risk perspective?

Accreditation

Compliance

Quality/Safety

Reputation

Efficiency




Examples of Risk Assessment in the Healthcare


Examples of Risk Assessment in the Healthcare




An integrated approach


What can Barrier Based Risk Managementmean for you?

A dashboard for management at every level to recognize the health of the assets

Comply with new Codes of Practice, build in flexibility to adapt

Make your operations more reliable and predictable

Decrease downtime / incidents / process deviations

Introduce the possibility to consolidate and compare risks and set standards for the sites

Combine compliance (reporting or endorsement) with internal/external audits, and with operational risk management

Where the weak spots are and what the status of improvements/action plans are

Make informed decisions on situations it is safe to provide the patients

Make informed decision on safety initiatives

Better use of resources, setting the right priorities




How to get more information?http://www.patientsafetybowties.com/Events in your regionConferencesTraining (in house or open training)Workshops (in house or open training)In house pilot with your people and your dataBowTie Examples LibraryCGE Website (www.cgerisk.com)Blog (www.cgerisk.com/news/cge-blog)Newsletters (www.cgerisk.com/news/cge-newsletters)CGE YouTube channel (www.YouTube.com/CGErisk)Feel free to call us (+31 88 100 1350)Use our software for a trial periodWebinars1-1 online WebEx meetingsFeel free to invite us for a meeting at your officeWe are happy to introduce you to other industry leading clientsOur network of local consultancy partnersSend us an email ([email protected])

Hu-Tech Human Factors 18/04/2017


Case Study: Developing BowTies in a

Healthcare Setting

Recognition and Management of Acute

Hypercapnic Respiratory Failure -

Derby Teaching Hospital NHS Foundation Trust

Items to cover

• Clinical background

• Patient Harm

• Incident Investigation

• HF approach

• BowTie Modelling

• Identification of barriers

• Focus of resources

• Rollout

• Audit

2



Clinical Background to Project

• AHRF is a Medical Emergency

– High mortality

– Requires timely intervention

• AHRF results from an inability of the respiratory pump and lungs to provide sufficient alveolar ventilation to maintain a normal arterial PCO2.

• pH <7.35 and a PCO2 >6.5 kPa is defined as acute respiratory acidosis

3

Rationale for Project:Poor recognition & management of respiratory failure

• Median time from admission to NIV 4.1 hours

• 58% of those receiving NIV waited >3 hours

• 45% admitted had no oxygen prescription

• 41% Trusts had no oxygen training programme

4



Aims of project - Funded by HEE-EM

• Improve the recognition of AHRF as a medical emergency

• Improve the management of AHRF

• Ensure safe administration of oxygen and reduce harm events

• Understand why this happens and if by education and changing process management of these patients, outcomes will improve

• Engage departments, Doctors & Consultants with HF approaches to risk management

5

STEP 1

Patient Harm - Investigation

• 3 cases produced for HF review

• Case Timeline produced in

• Barrier Failure Analysis (BFA)

• At Derby, 120 further cases were analysed over a 2-3 month period.

• AHRF had a 48.9% inpatient mortality rate, rising to 62.5% including first 30 days as outpatient.

6



STEP 2

Engage Staff at all Levels in HF Approach

• 3 workshops

• Explain BowTie, Human Factors and Barrier

Management

• Collect views and ideas about Barriers

• Some of the content follows…

7

Human Factors Approach to Risk of Harm

• Complex Systems have numerous ‘failure’ points, where an unwanted outcome is produced - these may begin outside the focus of a local system or investigation of incidents

• Not all ‘failure’ leads to harm - many incidents are captured and recovered by the humans in a system

• So if we only protect against ‘harm’ - we may not be sufficiently protecting against ‘failure’ (and its distant effects)

• If we only investigate past incidents - we may not be able to fix the current problem or predict future issues.

• There are complex interactions within and between each part of a system that can vary its effectiveness.

HF addresses the whole system to focus on critical elements

leading to failure and harm

8



Human Factors Solution Development

1. What is the process designed to achieve?

2. Which systems influence or deliver that process?

3. How might each system (or step within it) fail?

4. How do we recover from the outcome of that failure? (recovery barrier)

5. How do we prevent that failure? (pro-active barrier)

6. Can we design better systems that work to achieve the process?

The system design must support the positive actions of the human factor, while protecting against negative ones.

9

Bow-Tie Method

10

Top Event

Hazard

Hazard Top Event

Hazard

Threat

Top Event

Hazard

Threat

Threat

Consequence

Top Event

Hazard

Threat

Threat

Consequence

Consequence

Top Event

Hazard

Preventive

Barrier

Preventive

Barrier

Threat

Preventive

Barrier

Preventive

Barrier

Threat

Consequence

Consequence

Preventive

Barrier

Top Event

Hazard

Preventive

Barrier

Preventive

Barrier

Threat

Preventive

Barrier

Preventive

Barrier

Threat

Recovery

Barrier

Recovery

Barrier

Consequence

Recovery

Barrier

Recovery

Barrier

Consequence

Recovery

Barrier

Escalation

Factor

Top Event

Hazard

Preventive

Barrier

Preventive

Barrier

Threat

Preventive

Barrier

Preventive

Barrier

Threat

Escalation Factor

Recovery

Barrier

Recovery

Barrier

Consequence

Recovery

Barrier

Recovery

Barrier

Consequence

Escalation Factor

Top Event

Hazard

Preventive Barrier

Preventive Barrier

Threat

Preventive

Barrier

Preventive

Barrier

Threat

EF Barrier

Escalation

Factor

Recovery Barrier

Recovery Barrier

Consequence

Recovery

Barrier

Recovery

Barrier

Consequence

EF Barrier

Escalation

Factor

EF Barrier



11

• Describes the desired state or activity

• Is part of normal business

• Has the potential to cause harm if control is lost

• Defines the context and scope of the BowTie diagram

E.g.: Driving a car, hydrocarbons in containment,

landing an aircraft

Hazard

• Is a deviation from the desired state or activity

• Happens before major damage has occurred

• It is still possible to recover

• Hazards can have multiple Top Events

E.g.: Losing control over the car, loss of (hydrocarbons)

containment, deviation from intended flight path

Top

Event

• Are credible causes for the Top Event

• Are not Barrier failures

• Should lead directly to the Top Event

• Should be able to lead independently to the Top Event

E.g.: Driving on a slippery road, pipeline corrosion, loss of

positional awareness

Threats

12

• Are the hazardous outcomes arising from the Top Event

• Describe the direct cause for loss or damage

• Describe how the damage occurs

E.g.: Car rollover, ignition of vapor cloud, mid-air collision

Consequences

• Are factors that reduce the effectiveness of a Barrier

• Should be used sparingly to highlight real issues

Tip: Focus on critical Barriers

Tip: Avoid repetition and duplication

E.g.: Forgetting to wear the seatbelt, no maintenance done,

person not trained

Escalation

Factors

• Prevent, control or mitigate undesired events or accidents

• Can be (a combination of) behaviour and hardware

• A Barrier System contains a detect, decide & act component

E.g.: Wearing a seatbelt, Blow-Out Preventer, Ground Proximity Warning

Barriers

• Escalation Factor Barrier - Reduces the effect of the Escalation Factor

• Recovery Barrier - Avoids or mitigates the Consequence

• Preventive Barrier - Eliminates the Threat or prevents the Top Event



Use of ‘Barrier Thinking’

• Barriers are ‘good’ - they stop you getting somewhere you DON’T want to be

– Anything that reduces the effectiveness of a Barrier needs to be addressed

13

Use of ‘Barrier Thinking’

• Obstacles are ‘bad’ - they stop you getting

somewhere you DO want to be

14



Barrier or Obstacle?May depend who you ask……

15

Barrier Attributes

• Should be:

– Effective

– Reliable

– Robust

– Auditable

• What types of Barrier?

– Behavioural

– Procedural

– Socio-Technical

– Hardware

o Passive, Active or Continuous

16

RELIABILITY

Poor

Good Poor

Good

FLEXIBILITY



Understanding Barriers in Complex Systems

• Effective Barriers to system failure can be people, actions,

equipment, procedures, infrastructure etc.

• Each will perform at varying levels of effectiveness

• Effectiveness can be degraded (risk of failure escalated) by

a wide range of factors

• Each Escalation factor needs 1 or more barriers in place

• Each of those may be degraded in turn.……

This complexity is best managed & displayed using BowTie

17

STEP 3

Explore the Bow-Tie model for AHRF project

• Link to Bow-Tie XP

18



STEP 4

Development Areas from AHRF Bow-Tie

1. Awareness of AHRF clinical presentation, treatment and referral

2. Maintenance of Critical Information at handovers– Conflicts between competing systems (iCM, Patient

Track, written notes)

3. Accuracy and frequency of information (from Arterial Blood Gases)

4. Escalation to Senior Decision Maker - correct information and method

19

Exploded Diagrams - Prevention Barriers

20

Focus project

resources here



Exploded Diagrams - Escalation Barriers

21

Exploded Diagrams - Recovery Barriers

22

Focus project

resources here



Exploded Diagrams - Escalation Barriers

23

STEP 5

Interventions

• Training

– Simulation for AHRF recognition & NIV

– Taking of Arterial Blood Gases / use of Capillary

Blood Gases

– Ward based awareness of AHRF - (Superheroes)

– ACPs, F1 and F2 in awareness of system updates,

checklist use and case management steps

24



Interventions

• Electronic Information

– iCM auto-update of ABG results

– Alert developed for respiratory acidosis

– Flag links to AHRF immediate case management

checklist (electronic and hard copy available)

– Icon introduced to electronic whiteboard

25

Interventions

• Checklist for Immediate Case Management– Recording of action times to improve tracking

– Prompts for required actions such as: collecting ABG, prescription of correct target oxygen saturation, and use of wristband

– Assistance with decision making based on ABG results

– Guide to improve quality of referral to senior decision maker, including information to hand during call and clear script statements to assist communication under pressure

26



Next Steps

• Collect data for another 120 cases over 2-3 month period

• Determine impact from introduced and strengthened barriers

• Refine barriers based on feedback

• Audit barriers following identification of Leading Indicators - (F1 & F2 rotations, winter, iCM changes, Pharmacy space restrictions, etc)

• [See Audit Filter ‘on’ for AHRF model]

27

A year in the life of Bow-tie XP

Bryan Healy Head of Risk BWCH March 2017

Our story

1. The Background

2. The Paper BT

3. First ever deployment

4. My favourite story

5. A work in progress

6. Some interesting observations

7. Why I’m a fan

8. What’s next?

The background

• Saw these guys at a conference – Nov 2013?

• Intrigued but moved on.

• Then came across a problem.

• We wanted to refurb a ward

• But were terrified by the risk of dust

• But had to improve the patient experience, had made

commitments to patients and raised charitable funds.

• Our CMO said, “Could you do us a risk assessment?”

• So I did a bow-tie on paper…lots of paper

The paper BT

What ended with was

a map and that was

priceless.

The paper BT

• The bow-tie provided a model that everyone could understand

• Everything was on the same page

• Everything could be challenged

• Everyone was able to realise challenges in maintaining controls

• We had no appetite for the risk and the building work was cancelled.

Lesson 1: The bow-tie maps a system, giving a

holistic view of what’s going on, what interacts and

what’s important.

Sometime in 2015

• MY CMO sent me an e-mail from a friend of

his.

• That friend loved bow-ties, worked with CGE

and was doing a workshop in Birmingham.

• I went along

• I was impressed.

• I told my boss we needed this.

• We got it and then what?

Lesson 2: Making the case with a bow-tie

Lesson 2

The holistic view of this situation:

• Gave us the ability to articulate a complex story.

• Gave structure to the conversation.

• Had strong visual impact

Plus

• We’d developed a framework for potential future evaluation exercises

• And the software earned its’ stripes

• …so then what?

My favourite story

It took us 45

minutes

It is purely

qualitative

Each threat

represents a

different system

level

Lesson 3:

“We’ve spent weeks looking at this…I know what to do

now”

You don’t have to be an expert every time

You don’t have to complicate things

A work in progress

• SIRI.

• 10 x overdose (no

harm)

• Recommendation:

risk assess 10 x

OD.

• So we mapped

the system of

threats and

controls.

Zooming in

• And suggested

some escalation

factors. • Then began working

through ap.600 incidents

collected over a 6 month

period

Analysing Incidents

Recovering controls

13 Recognition: through checking processes for subsequent

administrations

14 Other Investigations / clinical monitoring

15 Blood test

16 Culture of secrecy

17 Monitoring alarms

18 Treatment

19 parent call for help

20 Clinical resuscitation

Preventing Controls

1 Nurse (administrator) double checking process

2 Pharmacist check

3 Prescription reviews by clinicians

4 Parental involvement in checking

5 Prescription training

6 Prescribing areas

7 Drug prep area

8 Use of smart pumps with drug libraries, hard and soft

limits

9 Drug labelling

10 Personal diligence

11 Double check of pump programming

12 Parental/ patient involvement in checking

Our most frequently failing controls

Preventative controls

Prescription

calculation

error

Unclear

Prescription

Transcription

error Wrong

preparation

Rate

Programme

error

Personal diligence 69% 67% 50% 21% 11%

Administrator double checking process 5% 0% 25% 71% 37%

Pharmacist check 12% 17% 0% 2% 0%

Prescription reviews by clinicians 10% 0% 25% 0% 0%

Double check of pump programming 0% 0% 0% 0% 37%

Recovering controls

Prescription

calculation error

Unclear

Prescription

Transcription

error Wrong

preparation

Rate

Programme error

Doses>0.1ml

Administrator double

checking process 35% 50% 25% 24% 26% 0%

Pharmacist check 16% 0% 25% 5% 5% 0%

Prescription reviews by

clinicians 4% 17% 0% 0% 5% 0%

Parental involvement 6% 17% 13% 3% 5% 0%

Checking for subsequent

administrations 16% 0% 13% 10% 32% 100%

Other Investigations /

clinical monitoring 2% 0% 0% 13% 16% 0%

A Lesson About Content

4. A useful aspect of BT is the ability to characterise barrier

types

All our controls are behavioural

This is the technical one

Another Lesson About Content

5. There is a hierarchy

of outcomes which

people always reach

for

Why I’m a fan

• When we couldn’t refurbish the ward,

something else happened

Oncology build BT

The Problem

• The new building is on

the other side of site.

• Will this delay our

assessment of acutely

ill patients?

• How would that come

about?

Oncology build BT

The Problem

• The new building is on

the other side of site.

• Will this delay our

assessment of acutely

ill patients?

• And what would that

mean for our patients?

Oncology build BT The Process

1. We met with the team and asked them their

worries

2. We talked through what would be needed to

mitigate the risk.

3. Together we mapped the worries

Oncology build BT The Process

4. We met again to discuss the BT

5. We talked through the controls and discussed how

far they are currently implemented

6. Then we could focus on how we might mitigate the

residual risk residual risk

Lesson 6

The BT is a powerful knowledge-brokering tool

KBT’s have 3 characteristics

• They are concrete.

• They represent relationships

between stakeholders.

• Anyone can change them.

• This has a form that the clinical

team came together around.

• It described the connections

which were important to them

• We developed it in a group

session – users could print it out

and stick it on the wall- scribble

on their ideas

A quick one

Quality Finance

Productivity

A quick one

Problem

Work Harder Unsustainable

Defect Correction

Sunk Costs

Tackle the problem

The smart answer

A quick one

Work Harder

Defect Correction

Tackle the problem

Summary

How we’ve used them Where we’ve used them

Problem solving Service

capacity

Investigations Never

Events

Analysis Medication

Errors

Needle-

sticks V&A

Info

Security

Infection

Control

Equipment Workflow

Final Thoughts A lesson about process

7. We’ve not integrated Bow-ties with our

business intelligence yet…and I don’t know

how to.

But the clue lies somewhere in answering a few questions:

• Is BT central to our risk strategy?

• What place bow-ties in an NHS addicted to incidents?

• Can we afford the full package?

Hu-Tech Risk Management Services 18/04/2017

1

Defences & Learning from Incidents

Rob Miles C.Eng C.ErgHF

Technical Director, Hu-Tech Risk Management

Services ltd

Reliability

Safety

Management

System

Adaptability

Threats

Engineered

defences

Procedural

defences

Human

defences

Near

miss

Incidents

Effective

defence

• Connections that only

fit one way

• IT flags that trigger

stop

• Barcodes and tags

• Procedures

• Checklists

• Handovers

• Supervision

Observation

Cross checking

Vigilance

What you walk past is

what you accept, is sets

the safety culture.

©Copyright Hu-Tech RMS ltd 2017


2

Label printed Medication issued Medication administeredMedication delivered

Patient deteriorates unexpectedly

Routine check

flags alarmSeverity is

understood

Emergency Treatment NHS LA Claim

Team GB


Diagnosis correct,

document misread

Diagnosis correct,

document misread

Label printed Medication issued Medication administeredMedication delivered

Patient deteriorates unexpectedly

Routine check

flags alarmSeverity is

understood

Emergency Treatment NHS LA Claim

Team GB

1. Root cause?

2. Last chance?

3. Current capture?

4. Best defence?



3

5


Learning From Incidents (LFI) We can use bowtie based investigation human factors investigation techniques to deliver LFI.

Investigation processIncident pathway

Failed opportunity to recover

Latent failure

Contributory

factorLatent failure

Root cause

Uncontrolled threat

Failed defences

6


Learning From Incidents (LFI) Bowtie based investigation for LFI is very effective for “close calls”.


Latent failure

Root cause

Uncontrolled threat

Failed defencesThe wrong medication was

given, but this was

“captured” by effective

monitoring and mitigated by

rapid intervention.

Zero harm

Despite there being “Zero harm” the

LFI investigation will uncover the

same root cause


4

7


Learning From Incidents (LFI) We can use the Bowtie approach extract learning from past investigations (LFI)


Latent failure

Root cause

Failed defences Investigations tend to stop

with the Top Event as a root

cause. This provides very

little opportunity for LFI.

Sometimes “who” is given as

a root cause.

Sometimes the Uncontrolled

threat given as the root cause, but

this lacks detail on where to make

improvements

LFI takes place when the failed

defences are identified and action

taken to strengthen them.

This operational defence

failed, it is the immediate

cause, not the root cause

8


Learning From Incidents (LFI) For LFI to be effective there must be sustainable improvement: KPIs.


Latent failure

Root cause

Failed defences




The improved defences

become KPIs for follow-up

and audit



and audit

These LFI KPIs can be dealt

with on a sampling basis to

avoid overloading the

monitoring system.

They can also act a triggers to

alert to repeated incidents.


5

9

Ahead of events

– errors do not

occur – leading

indicators LFI

Resilience –

errors do not

equal disaster

Where do you

spend your day?

Near – misses –

some failed

defences, some

working

Unsafe conditions –

weak defences

Clearing

up the

mess

Weeks £ Days ££ Hours ££££ Minutes ££££££ £Ms

label £10 procedure £50 urgent care £500 ICU £10000 £2.5M life care

Deepwater Horizon $20BN

CALM Firefighting


10

Defence Condition Accidents

Safety climate surveys

Friends and family

Customer surveys

Staff focus groups

Staff blogs?

Audits

Inspections

KPIs for defences

Human Factors metrics

Dangerous condition

System near-misses?

Reportable near misses

Witnessed events

Front line failures

Dangerous situations

Cancellations?

Serious avoidable harm

Never Events

Litigation

Time available

Verifiability

Utility

Leading Lagging

Sentiment

Opinion

Near Misses

Leading Lagging

Leading Lagging

Minor harm?

Healthcare

Co

ve

r-up

, de

nia

l, litiga

tion



6

11

Defence Condition Accidents

Safety climate surveys

Friends and family

Customer surveys

Staff focus groups

Staff blogs?

Audits

Inspections

KPIs for defences

Human Factors metrics

Dangerous condition

System near-misses?

Reportable near misses

Witnessed events

Front line failures

Dangerous situations

Cancellations?

Serious avoidable harm

Never Events

Litigation

Time available

Verifiability

Utility

Leading Lagging

Sentiment

Opinion

Near Misses

Leading Lagging

Leading Lagging

Minor harm?

Healthcare

Co

ve

r-up

, de

nia

l, litiga

tion

HealthcareRail

Offshore oil &gas Offshore oil &gas

Air traffic control

Healthcare


12

Every Defence

has a +ve

Human

Element*

Detect /

Decide / Act is

a single

defence

Human Error

is NEVER a

threat

The human

element can

fail, put it here

Human factors

goes here Show all

defences,

including

contractors

This is

contractor

audit and KPI

This where the

HF KPIs come

from.

©Copyright Hu-Tech RMS ltd 2017 [email protected]

Partner OrganisationStaff BowtieXP trained / MIST Survival Vantage

*monitor, decide, operate, maintain, inspect, audit, verify, specify, procure..

This is how to

categorise

near-miss

reports

Humans are a

GOOD THING


7

Learning From Incidents - LFI

Rob Miles C.Eng C.ErgHF

Technical Director, Hu-Tech Risk Management

Services ltd

No need to investigate, cut and paste : “tragic accident, unique circumstances, lessons will be

learned….report withheld to protect the family…”

Zero tolerance for repeated mistakes

Our suffering must be used to prevent others’ in future….

NO serious accident has EVER occurred without a NEAR MISS beforehand.

A failure to prevent repeated events is a 100% reliable indicator that an

organisation is poorly managed from the Board down.



8

Event

CaptureReview of

Defences

Immediate

Actions

Lessons for

the future

Action

Tracking

Validation

Verification

Simulation

Stronger

Defences

Root Cause

Investigation

Importance

Events elsewhere

EVENT

Safety alerts

Experience

elsewhere

Staff Report


LFI is not the same as investigation!

Investigation• Interview alone

• Challenged

• Names taken

• Strict remit, directed at single event

• Culpability

• Takes time

• Has legal implications

• Career alert

• Focused on identifying a single causation

• Delivers an explanation

Learning• Group discussion

• Open listening

• No blame (subject to

speaking up)

• Rapid – in time to make a

difference

• Comfortable with multiple

scenarios

• Objective is simplest

preventative measure

• Solutions can target similar

(and dissimilar) events.



9

1.Retained object

2.10x dose

3.Wrong name – on patient

4.Wrong medication – name

5.Wrong route administration

6.Slow decline to death (not from primary illness)

7.Key information omitted at handover

8.Fatal fall on loose floor covering / stairs; aged partner

9.Fatal vehicle accident in hospital grounds; elderly driver

under treatment at the hospital


Happened

before, many

times

Detailed

important,

specific

Paperwork,

handover, system

Fall on stairs Retained object Wrong notes



10

Happened

before, many

times

Detailed

important,

specific

Paperwork,

handover, system

Require action not

investigation,

generate solutions

and get them in

place.

In depth investigation

with specific

recommendations

Tend to be simple but

neglected. Significant

potential savings


Happened

before, many

times

Detailed

important,

specific

Paperwork,

handover, system

Require action not

investigation,

generate solutions

and get them in

place.


with specific

recommendations



potential savings

TRIAGE for Learning Potential



11

Happened

before, many

times

Detailed

important,

specific

Paperwork,

handover, system

Require action not

investigation,

generate solutions

and get them in

place.


with specific

recommendations



potential savings

TRIAGE for Learning Potential


Think

DEFENCES!

Set a standard for success:

• Defences based approach

• The solution is practical

• It prevents similar incidents – walkthrough

• It makes the job easier – self sustaining

• Staff buy in to the solution

• It contains no names!

LFI investigation procedure should fit on one wall chart



12

23


Learning From Incidents (LFI) For LFI to be effective there must be sustainable improvement: KPIs.


Latent failure

Root cause

Failed defences






and audit



and audit

These LFI KPIs can be dealt

with on a sampling basis to

avoid overloading the

monitoring system.

They can also act a triggers to

alert to repeated incidents.

24

Every Defence

has a +ve

Human

Element*

Detect /

Decide / Act is

a single

defence

Human Error

is NEVER a

threat

The human

element can

fail, put it here

Human factors

goes here Show all

defences,

including

contractors

This is

contractor

audit and KPI

This where the

HF KPIs come

from.


Partner OrganisationStaff BowtieXP trained / MIST Survival Vantage

*monitor, decide, operate, maintain, inspect, audit, verify, specify, procure..

This is how to

categorise

near-miss

reports

Humans are a

GOOD THING


13

1

29

300

1

30?

300?

Twisted ankle

Fatal fall

on stairsAvoidable death

Employee Safety Patient Safety

Major Waste

Irritation

1

30?

300?

3000?

Care Delivery

Record, results, labels, charts

Handover, checklists, procedures, wash-ups

Training, competence, supervision, oversight

Shared

defences

Shift rota, staffing, schedules


A weak defence is can undermine protection against many threats

Human Error

Success or failure?

You must be:

• Open and welcome reports

• Open minded about solutions

• Cut across boundaries

• Ignore status

• Engage outside the organisation:

Supply chain

Family

Contractors

You will fail if:

• Ignore, supress cover-up or redact

• Staff stay in silos

• You rule out novel or unusual solutions

• Favour senior staff

• Do not mobilise all relevant to the solution


• Intentionally weakening a defence.

• Not reporting a weakened defence.

Just culture



Never Event Investigations –

Reflections from a Trust Programme

Owen Bennett

Head of Patient Safety [NUH]

Expert Advisor – Sign up to Safety Campaign

Hu-Tech Human Factors

Agenda

• Declarations of Interest

• Context & Background of Never Events

• Never Events at NUH

• Barrier Analysis - Overview

• Complexities of Solution Development

• Table top discussions

• Questions Hu-Tech Human Factors



3 things we should all agree on

The best people can make the

worst mistake

No systems is perfect

Humans will never be perfect

3 Things we should all agree on…


Harm specificCross system &

Human Factors

Fatigue

Observation

Communication

Information

Medicines

Falls

VTE

Sepsis

Competing Priorities




Context & Background of Never Events

Financial Year National [n]*

16-17 [to 31.1.17] 351

15-16

[March 15 revised list)

442

14-15 306

13-14 338

12-13 329

*https://www.england.nhs.uk/patientsafet

y/never-events/ne-data/

**Surgical case load and the risk of surgical

never events in England. Article

• NE are important because they do

impact patients, relatives and

staff.

• NE are no more important than

other SI’s.

• NE are not a useful metric to

judge safety and the quality of

care**


Incident Reporting Rates

Positive reporting culture [39.85 per 1000 bed days] – April to Sep 15

0

10

20

30

40

50

60

70

0 50000 100000 150000 200000 250000 300000

Rate

per

1,0

00 B

ed

Days p

er

Year

Bed Days

Incidents per 1000 Bed Days for Acute Trusts (non-specialist)

Data

Average

2SD limits

3SD limits

Source: Incidents which occurred between 1st April 2015 and 30th September 2015 (reported to the National Reporting and Learning System (NRLS) by the 30th

November 2015)




Days between Never Events at NUH

Days between Never Events (by date of incident, 2011 to Sept 2016)


Analysis of 9 Never Events

September 2015 to August 2016 (12 rolling months) - 9 Never Events reported:

• None – death or serious harm

• 3 – moderate patient harm

• 6 – low patient harm

Common themes/features:

• 2 retained swabs [same dept]

• 2 incorrect pairing surgical implant [different depts]

• 2 epidural prescriptions given IV [different depts]

• 2 oral medication given IV [morphine, haloperidol – different locations]

• 1 Wrongly placed NG tube




Analysis of 9 Never Events

Applied taxonomy [retrospective]

1. Clarity of Policy/Guidance

2. Physical Connection, design (designing out error)

3. Second checking process

4. Process – deviation form the “norm”

5. Handover/Handoffs

6. Knowledge Base

7. Clarity of Prescribing


Kellogg. K (et al). 2017. Available online at:Here




Barrier Impact Analysis & Interventions

• Barrier Impact Analysis [old NPSA]

• Lee and Hirschler’s considering the strength of actions


Results

• 9 Never Events Reviewed [Report and Action Plan]

• Open disclosure and apology to the patient & / or relative

• In all cases patient/family invited to meet in person re report

• 175 actions described




Results


Results




Results


Reflections

• Excessive recommendations/actions

• Predominance of weak interventions (re education, policies)

• Focus on changing actions/ behaviours of individuals – not

the system

• Stronger interventions often not identified (or) implemented

– degree of influence

• Implications – training, capacity and capability




Summary

• Nationally – no real reduction in reported events

• Mean time between NE -80 days (in one large Acute Trust – positive reporting

culture)

• NE are important but must not distract from often more significant events

• Not useful metric to judge safety / quality

• Generally associated with low or no harm

• Excessive recommendations / actions [local & national]

• Predominance of weak interventions

• Implications – training, capacity and capability


Table – Top Work (10 mins)

• Review the recommendations / actions from the Never Event

• Discuss as a group the strength of the proposed actions (below may support)


bowtie in healthcare - hu-tech

Documents