Learning from Adverse Incidents

Hazel BairdHead of Governance & Patient Safety

Northern HSC Trust

To err is human ………..

Institute of Medicine 2000

Approximately 1 in 10 patients experience avoidable Harm or suffering due to mistakes in hospitals

Do we think?

• If a professional is highly trained and tries hard enough he/she will not make mistakes

• Errors and mistakes equate with personal failure and incompetence

The perfection myth

If we try hard enough we will not make mistakes

If we punish people when they make mistakes they will make fewer of them

The punishment myth

In reality ……

95% of errors that cause harm involve conscientious competent individuals trying hard to achieve the bestoutcome for those in their care

Only 5% of harm is caused by incompetence or poorlyintended care

“The organising principle is that the cause (of preventable harm) is not bad people but bad systems”

Lucian L Leape

Clinica.chinica acta. Vol 404 June 2009

Leape further suggests that in our healthcare systems:• The focus should be on systems not individuals when

errors occur

• There should be greater transparency and less secrecy

• Care should be patient centred and

• There should be a greater dependence on teamwork not individual performance

• Patients (carers) should be more fully engaged in their care

Open and fair culture

Staff must feel safe to report incidents and safety issues

To achieve this, the incident investigationmust be

• Fair and equitable• Focused on learning and change• Focused on identifying contributory and root causes

RCA example of 5 whys?• Nurse didn’t complete obs sheet why?• There were 3 obs sheets why?

she completes one• Pilot new obs sheet 2 years ago why?

original obs sheetone for post-surgery

• Obs policy working group why?hadn’t met for 6 months

• Work pressures and obs policy wasn’t priority why?• Development of obs policy not written

into anyone’s objectives

The basic premise of the systems approach to reducing error is that humans are fallible and errors are to be expected

“Therefore measures to reduce errors needto build defences within the systems in which humans work”

James Reason

Human Error-Models&Management

Case History• Mrs Brown 88 years admitted to hospital from pnh with history

of pyrexia, vomiting and falls

• Past history of stroke, chf and ischaemic heart disease poor short term memory

• Rx i.v. antibiotics and i.v. fluids

• 4 days later at 4am found face down on floor at side of bed. floor wet urine sustained head injury that led to her death 3 weeks later

• 1 month later Mrs Green admitted to another hospital in the trust. Sustained a fall and died from head injury

Investigation Methodology

• A time line was created• Notes examined• Problem identification – questions to be addressed • Staff interviewed• Policy position explored• Falls and bed rail literature reviewed

Questions to address• Was Mrs Brown’s risk of falling recognised, managed and

communicated between wards?• Was professional record keeping of an acceptable standard?• Were Mrs Brown’s needs appropriately communicated between

wards?• Did movement between wards adversely affect Mrs Brown’s

care?• What is the trust’s policy position on the assessment and

management of patients at risk of falls?• How does the trust’s falls rate benchmark against other

hospitals?• What resources are available to staff to try to prevent falls in

hospitals or reduce injury from falls?

Date Time Ward Duration in Ward

Reason for moving Notes

2/10/07 00:40 hrs AAdmission Unit

17 hours Patients are moved from Admission Unit usually within 24hours

Multi-disciplinary progress notes

2/10/07 17:40 hrs B 25 ½ hours Medical request for telemetry on Cardiac Ward

Multi-disciplinary progress notes

3/10/07 19:15 hrs C 26 hours Needed the Cardiac bed

Nursing progress notes

4/10/07 21:00 hrs D 31 hours After 31 hours, Mrs B sustained a fall with serious injury

Multi-disciplinary progress notes

Recommendations

• Patient movement between wards needs to be reviewed, this is particularly important for elderly, confused patients. Clinicians should be asked to consider the merits of moving an elderly patient for telemetry, versus the overall care issues it creates for them.

• Transfer checklists are a useful tool to ensure essential information is communicated between wards, but a field for ‘risk of falling – special measures needed’ should be considered. All forms should be signed.

Recommendations, contd..

• Recording formats for patient notes should ideally be standardised, so that there is clear continuity of recording between wards and across the Trust. Problems experienced by the review team may also have been experienced by ward staff.

• The use of multi-professional progress notes and care planning documentation needs to be reviewed and if they continue to be used, there should be explicit guidance and standards developed for their use.

Recommendations, contd..

• A simple audit of standards for professional record-keeping should be implemented six to twelve-monthly, as resources permit.

• A Trust-wide policy on prevention of falls in hospital and the safe use of bed rails should be developed. These policies will address risk assessment and care planning and will need robust implementation plans.

Recommendations, contd..

• The risk management department and service should discuss improvements in recording outcomes from falls.

• The Trust should discuss with DHSSPS colleagues the benefits of regional benchmarking and possibly national benchmarking through NRLS.

To maximise learning; you need• A good investigation team• A well structured report• Clear conclusions and recommendations with

associated action plan• The report and ‘learning’ shared in department,

directorates, organisation other organisations in a constructive way

• To evidence the delivery of the action plan and• Audit compliance issues to provide assurance

“ The names of the patients whose lives we save can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken and work completed, and books read, and symphonies heard, and gardens tended that, without our work, would have been only beds of weeds”

Donald Berwick, President of the Institute for Healthcare Improvement