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Clinical Safety & Systems
Improvement
Dr N Maran FRCA FRCSEd
AMD for Patient Safety NHS
Lothian
1
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Quality addresses the intended results of a system
– safety,
– efficiency,
– effectivenesss,
– equity,
– timeliness &
– patient (& staff) experience
2
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Patient Safety
“The avoidance, prevention and amelioration of
adverse outcomes or injuries stemming from
the process of healthcare”
Vincent 2010
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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*
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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
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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
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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
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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
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Datix reporting NHSLothian 2017-19
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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
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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
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harm is more often the result of lack of diligence in performing ordinary tasks rather than a lack
of extraordinary skills
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The Scottish Patient Safety Programme
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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
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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
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Sustainable universal implementation with high levels of reliability
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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
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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
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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
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Hospital Acquired Infection
C Diff
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22
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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
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Patient safety - opportunities
• Local improvement work
• Quality improvement teams (QIT)
• Cardiac arrest / deteriorating patient work
• Mortality reviews
• SAE reviews
• Simulation faculty
24
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QI opportunities & resources
25
• Lothian Quality Academy
• NES Quality Improvement courses
• SPSQ fellowships
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Questions?