quality education for a healthier scotland enhanced sea chris williams, paul bowie, elaine...

Quality Education for a Healthier Scotland

Enhanced SEA

Chris Williams, Paul Bowie, Elaine McNaughton, Duncan McNab, John McKay & David Bruce


Plan

• Analysis of SEA currently• Why enhanced SEA?• Human factors in SEA• Why we blame • Why error occurs• Enhanced SEA process • Results of pilot• Example


What is a Significant Healthcare Event?


Current expectations of SEA in GPST

• Reflecting and learning from interesting or complex cases or important safety events

• Identifying individual or practice training needs, and system weaknesses

• Facilitating the rapid implementation of change and improvement

• Contributing to the management of risk in the practice

• Enhancing the safety of patient care and local safety culture


Investigations of Significant Events Poorly

Conducted:

Problems• Incidents are highly selective (or non-engagement)

• Lack of a structured analytical framework (long standing issue)

• Many SEAs demonstrate a lack of ‘systems thinking’

• Most clinicians attribute events to their own actions/inactions


Investigations of Significant Events Poorly Conducted:

Impacts

• Missed opportunities to learn & improve (personal, team & organisational)

• SEA becomes a tick-box exercise

• Perceived blame culture (fear, distrust, punitive action, litigation…)

• Negative feedback (interferes with ability to assimilate & process information beyond the ‘self’ level)

• Second-victim syndrome (impact on health & wellbeing of clinician: guilt, embarrassment, shame…)


Why enhanced SEA?

• Overcome SEA deficiencies by introducing human factors systems principles

• Highlight and differentiate the interactions between the individual , their workplace and wider organisation.

• Individual Level: guide clinicians to reflect upon and contextualise their emotional reactions - achieve a state of psychological readiness to move on.

• may lessen –ve emotional reactions and apportioning of personal blame

• Team Level: a systems-centred analysis of the significant event. • may lead to more meaningful and effective action

plans for improvement.


Human factors (Ergonomics)

• The interaction between humans, systems and the environment

• What it is NOT!

– “This mistake was caused by human factors.”


Human Factors (Ergonomics) in Healthcare

• In healthcare, it can be used to design all aspects of a work system to support human performance and safety, and prevent errors that may harm patients.

Its goals are twofold:• To support the cognitive and physical work of

healthcare professionals, and• To promote high quality, safe care for patients


Awareness of human factors principles can help GPSTs to:

• Understand why errors are made and which ‘systems factors’ threaten the safety of patients

• Learn about and help to improve the safety culture of teams.

• Enhance teamwork and improve communication between healthcare staff

• Improve the design of “healthcare systems” and equipment

• Identify ‘what went wrong’ and predict ‘what could go wrong’


Why do we blame?

• Convenient

• Prosecute

• Appease patients and public

• Psychological factors


Blaming ‘Skills’• Hindsight Bias - this is the ‘I-knew-it-all-along’ effect

• The Illusion of Free Will - Most of us believe that we determine our own actions (most of the time) In other words, they ‘choose’ to make mistakes.

• Fundamental Attribution Bias -Our natural tendency is to attribute someone’s actions (especially undesirable actions) to their personality traits or characteristics while (unintentionally) ignoring contextual contributory factors that may have constrained their actions.

• Just World Hypothesis -We also assume that ‘bad’ things only happen to ‘bad’ people


Human Error

“Errors are the inevitable and usually acceptable price human beings have to pay for their remarkable ability to cope with very difficult informational tasks quickly and, more often than not, effectively”.

Reason (1990)


Human error• Short-term memory capacity

• Gap between the level at which we expect to perform and reality

• Attention spans

• Our judgment will fail us

• Stress, fatigue and awareness levels can affect our judgments or perceptions


Types of Error

Active Errors:• These are committed by frontline staff and

tend to have direct patient consequences

Latent Errors (or System Errors).• Latent or system errors create the conditions,

context and potential for Active Errors. They seldom have immediate consequences, but can potentially affect many more patients


Human error – a systems approach

“Error is not the monopoly of an unfortunate few” - when placed in similar circumstances, the majority of people will make similar mistakes.


Enhanced SEA


Enhanced SEA• Part 1– Address the personal and wider

impact

• Part 2– Adopt a human factors framework

to analyse why event occurred

• Part 3–Define the action plan


Guide Tools

• Small Personal Booklet (with 4 card inserts)

• A3 size Desk Pad

• New written format for enhanced SEA reports


1. A small 12-page Personal Booklet (with 4 card inserts) to help individuals reflect on the potential emotional impacts of a significant event - and their own role in the event - by using human factors principles to gain a clearer understanding of all of the contributory factors involved.


2. An A3 size Desk Pad for the care team, the sheets from which can be distributed to all those who attend a team meeting to analyse significant events. Each sheet contains instructions and prompts to guide the care team to take a systems-based approach to analysing the event in question and take notes on what was agreed – a small set of card prompts may also be used in conjunction.


3. A re-designed written report format for enhancedSEA – to prompt a systems based analysis.


1.About the Significant Event

Please describe what happened (e.g. outline in sufficient chronological detail including how it happened, who it happened to and the location of the event). What was the impact or potential impact of the event? (e.g. on the patient/relatives, yourself, colleagues/staff – think in terms clinical, professional and organisational risks and implications).


2.Contributory Human & System Factors

Please outline the different factors that contributed to WHY the event happened.

People Factors (e.g. consider the people (ill patients/clients, staff interactions) who were directly and indirectly involved in the event and the communications between them and other factors). Activity Factors (e.g. complexity of the work task, lack of recognised care guidance or design of system or process). Environment Factors (e.g. consider practice culture, time and workload pressures, adequacy of equipment, available lighting, noise levels, distractions and interruptions. Please describe how these factors combined to make the event happen. (Think in-depth about the interactions between people, the activity you were undertaking, the practice and wider healthcare systems and environment that you work in).

Did you identify these factors on your own or with input from other colleagues?


Interaction of factors


3.Lessons Learned

What lessons have been learned from the analysis of this event? (Think again about the complex interactions between People, Activity and Environment).

What learning needs have been identified (at the individual, care team, and organisational levels, where appropriate)?


4.Action Plan for Improvement

How have you minimised the chances of this event happening again? (Outline your Action Plan for Improvement and how you have implemented it together with the role and contribution of the wider care team, where appropriate. If you have yet to take action or judge that no action is necessary, please justify why this is the case).

Who is responsible for ensuring that these actions are implemented and how will these be monitored and sustained in practice? (Outline your role and contributions and those of the wider care team, where appropriate).


Statement and levels of agreement (%) Pre- Post-

I have a good understanding of what a "significant event" is in the context of my healthcare role 82 95*

I fully understand how to undertake and lead a significant event analysis 66 95*

When a significant event is analysed, it feels like the person is being written up, not the problem

19 13

Poor design of systems, rather than the actions of humans, is the biggest factor contributing to significant events in the workplace

39 50*

I have a good understanding of the discipline of “human factors” 35 77*

Highlighting significant events is a good way of identifying staff who need additional training

24 34*

I think undertaking SEA is a demanding and difficult task 48 52

Evaluation (n=117)

*P<0.05


Early Feedback from SEA Peer Reviewers

Subjective/Objective Comparisons – ‘Old’ vs ‘New’

• Acts as a ‘forcing function’ – deeper analysis

• More straightforward to actually understand and peer assess

• Feeling that more challenging events are being selected

• Overall standard has improved compared with ‘old’ system


“normal” vs “enhanced” SEA


Overall Impact of enhancedSEA

•“I think it was definitely the most thorough SEA that we’ve done for a while and everybody commented that it went very well and it had some very good outcomes for us all things that I really think will have a decent impact”

•“I think it’ll get people to think more into just why significant event analysis happens and it’s like a big elephant in the room, of course you’re embarrassed and you will have these emotions and I think it encourages people to realise that those emotions are there, we’re not working as robots if you like. And it gets people to think more about being human”


Overall Impact of enhanced SEA

• “I found it made the process more laborious and confusing in some ways. I think the booklet was helpful but the report format needs to be simplified. Some of it felt like writing in order to fill in boxes. I think we would have come to the same conclusions if I had used our normal format”.


SEA unopposed oestrogen HRT

• 50 year old lady

• No period in 18 months

• Attended ST3 requesting HRT patch

• Prescribed Evorel 25.

• HRT review 1 month later with nurse – inadequate control symptoms

• PC with ST3– increased to Evorel 50


Unopposed oestrogen

• Review with nurse 1 month later – HRT review performed and recorded

• 3 month prescription printed and GP asked to sign between patients

• Review with nurse 3 months later

• Further 3 month prescription and again signed by GP between patients.


Unopposed oestrogen

• Attended GP partner feeling tired

• Reported 3 months of heavy PV bleeding

• GP double checked HRT– Apologised– Gynaecology referral– USS


Consider personal impact on ST3

• “Devastated”

• Loss of confidence

• Was very worried about discussing at SEA meeting


What would their first thoughts be?

• Probably – Guilt– Self blame– Educational need

– “Will try not to do this again.”


Consider impact

• Patient

• Other patients

• Practice


Consider people factors

• Patient

• ST3 - Training

• Nurse – training, experience

• GP who signed prescription


Consider activity

• HRT review

• EMIS prescribing

• EMIS template

• System in place for getting prescription signed


Consider environment

• Busy surgery

• 10 minute appointment for HRT review

• GP signing prescription between patients– Unlikely to check– Unlikely to question

• Training


How did this combine?

• Easy mistake to make due to systems (EMIS)

• Time pressure (ST3, GP, nurse)

• Trying to save patient delay

• Simple mistake not picked up


Action plan• Apology

• EMIS warning

• HRT template on EMIS with box to check type of HRT

• Include HRT in “high risk” medicines tutorial at start of training

• Have practice “preferred list” of HRT in each room

• Training of GPs and nursing staff

• Regular audit - monthly

• Nominate who is responsible for each action


Enhanced SEA - Summary

• Enhanced SEA helps

– Discuss “difficult SEAs” which are often PSIs

– Get to the bottom of WHY the event happened• Exploring people, activity and environment

– Develop and action plan to reduce the risk of recurrence


QUESTIONS?


Enhanced SEA – more information

• www.nes.scot.nhs.uk/shine/

quality education for a healthier scotland enhanced sea chris williams, paul bowie, elaine...

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