patient safety: where to now? clinical cultures · – improves overall leadership awareness of the...
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Patient Safety: Where to now? Clinical Cultures
Dr Bernadette Eather NSW Director Patient Safety, CEC
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Patient Safety- Where to now? • Safety Culture • Identification
– Data triangulation – Reporting
• High reliability • Safety II • Human factors/team work training • Focus on microsystem
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What is safety culture? The complex framework of national,
organisational and professional attitudes and values within which groups and individuals
function that influence the safety of an organisation
Or
The way things are done around here
•(Helmreich & Merrit, 2001; Sexton, et al, 2003)
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Characteristics of Safety Culture • Leadership commitment • Open & frequent communication (trust) • A just culture • Robust systems • Organisational learning • Team work • Awareness
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Patient Safety Leaders: • Understand risk • Take action to mitigate patient risk • Are proactive • Report • See a problem and don’t ignore it • Don’t blame individuals • MAKE CHANGES to transform the workplace
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Patient Safety II
• High reliability – An organisational structure and team-work
based safety culture so that inevitable human mistakes do not lead to patient harm. This methodology differs from previous quality and safety efforts, in that it simultaneously emphasises interprofessional interventions, behavioural changes, structured leadership, and culture shifts towards a culture of safety as a core value…
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High performing health care • Organisational design- standardise practice,
reduce complexity, learn from mistakes • Organisational work- commitment to safety,
blame free, resources, encourage collaboration
• Organisational focus- preoccupation with potential failure, focus on near miss, teams, deference to frontline expertise
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Content
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Clinical incidents notified in IIMS by Actual SAC rating, January 2011 - June 2015
IIMS Clinical Incident Monthly Notifications 2005 – 2015
400050006000700080009000
100001100012000130001400015000160001700018000
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Axis
Titl
e
NSW Clinical Incident Notifications 2010-2015
2010
2011
2012
2013
2014
2015
Linear (2015)
Increased reporting rate of 5% each year
2015Jan-Jun Jul-Dec Jan-Jun Jul-Dec Jan-Jun Jul-Dec Jan-Jun Jul-Dec Jan-Jun
SAC 1* 269 309 290 308 306 302 252 262 238SAC 2 1,269 1,411 1,258 1,378 1,285 1,261 1,401 1,424 1,342SAC 3 29,059 30,688 30,355 32,675 33,849 34,524 36,007 39,343 39,462SAC 4 32,869 34,775 36,085 37,212 37,652 40,264 39,213 41,899 42,831No SAC Allocated 2,994 3,752 3,619 3,595 2,079 2,884 3,034 1,998 2,926TOTAL 66,460 70,935 71,607 75,168 75,171 79,235 79,907 84,926 86,799
SAC Rating 2011 2012 2013 2014
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Clinical Management RCAs
• Total of 443 Clinical Management RCAs received January 2015 – June 2016
• Of the 443 RCAs, 93 (21 per cent) were allocated specific service Emergency (ED)
11
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Clinical Management RCAs
12
1.08
1.08
1.08
3.23
3.23
3.23
3.23
4.3
4.3
6.45
7.53
7.53
9.68
9.68
15.05
19.36
0 2 4 6 8 10 12 14 16 18 20Percentage
Local Health Districts as a percentage of ED RCAs January 2015 - June 2016
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Clinical Management RCAs
13
4.3
7.53
13.98
23.66
31.18
0 5 10 15 20 25 30 35
Death following fall
Non-preventable outcome
Diagnosis - delayed
Treatment - inadequate
Diagnosis - missed
Percentage
Top five Principle Incident Types as a percentage of ED RCAs January 2015 - June 2016
The PITs of Diagnosis – missed and Diagnosis – delayed represent 45.16 per cent of RCAs from specific service ED
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Clinical Management RCAs
14
DP – Deteriorating Patient *multiple responses are allowed
12.9
15.05
17.2
17.2
20.43
28
30.11
33.33
57
65.6
0 10 20 30 40 50 60 70
Acute coronary syndrome
D/P - inapp/delayed response to esc
D/P - delay/failure to escalate
eMR
Sepsis
BTF charts/altered criteria
Acute abdominal pain, incl. AAA
ED representation
D/P - failure to recognise
Out of hours presentation/admission
Percentage
Top 10 Clinical Risk Groups* as a percentage of ED RCAs January 2015 - June 2016
The recognition and management of deteriorating patients is a significant patient safety issue.
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Clinical Management RCAs
15
29.03
30.11
35.48
35.48
41.94
44.09
63.44
69.89
73.12
75.27
0 10 20 30 40 50 60 70 80
Supervision - Support inadequate
Environment - Activity
Obs & Monitoring - Physical/physiological obs inadequate
Policy/GL - Not implemented
Obs & Monitoring - Sig not recognised/responded
Care planning - Care coordination
Communication - Inadequate between care providers
Communication - Documentation inadequate
Assessment - Physical health
Care planning - Inadequate care plan
Percentage
Top 10 System Factors* as a percentage of ED RCAs January 2015 - June 2016
*multiple responses are allowed
Communication and Care planning are prominent issues in the delivery of safe and reliable patient care
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Contributing factors Problems with communication remain the single most frequent cause of serious adverse events • Shift handovers • Handovers between teams • Ward/Department transfers • Inter-hospital transfers
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Communication problems
• Doctor/nurse interactions –Different terminologies – “Going Off” •Different expectations •Recipients
• Medication orders •Similar names/different medications •Lasix and Losec
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Human Factors • We all have different skills • We all think differently • We perform tasks based on experience • Individual or team level
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How we make decisions
Control modes
Situations
Rule-based Trained-for problems
Mixed
Skill-based Routine
Automatic
Knowledge- based
Novel problems
Conscious
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Skill-based slips
and lapses
Errors
Attentional slips of action
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A common lapse
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? The cure
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Skill-based slips and lapses
Errors
Attentional slips of action
Memory lapses
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Skill-based slips and lapses
Errors
Attentional slips of action
Memory lapses
Rule-based mistakes
Knowledge-based mistakes
Mistakes
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rejected
False hypothesis error
Incorrect hypothesis
Allnutt M, 1983
Tailored to fit
New information
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Air New Zealand Flight 905, 1979
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Safety Huddles - Why Increase and maintain situational awareness
– Improves overall leadership awareness of the status of front-line operations
– Provides timely recognition and resolution of problems that impact outcomes
– Provides for alignment and focus of the leadership team around safety and key operational issues
An effective daily safety huddle: – Communicates the urgency of resolving safety issues and critical
situations – Allows the team to plan for the unexpected – Allows team members’ needs and expectations to be met – Uses concise and relevant information to promote effective
communication
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Leadership, culture, partnerships
• Leadership programs • Coaching • Increase focus/awareness • Best practice examples • Universities • Consumers
• Exec walkrounds • Safety huddles • Handover/communication • Team based training • Target local programs
Priorities
Outputs of high reliability
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Questions? Dr Bernadette Eather
Director Patient Safety | Clinical Excellence Commission p. (02) 9269 5506 | m. 0413316591|
Level 17, 2-24 Rawson Pl Haymarket NSW 2000
Locked Bag 8 Haymarket NSW 1240
Tel: +61 2 9269 5500
www.cec.health.nsw.gov.au