Background to Patient Safety
Post Fellowship Skills Course
Patient Safety is...
‘The avoidance, prevention and improvement of
adverse outcomes or injuries stemming from the
process of healthcare’
(Vincent, 2006)
• Policy
• Theory
SPSP
Revision of goals at
the end of the first
phase of Acute
Adult Programme
SPSP
•Mental Health
•Maternity
Primary Care
SPSP - Sepsis/VTE
Medicines Management Network
Safety in Primary Care
SPSP Paediatrics
SPSP 5 Acute Adult Care Workstreams
Safer Patient Initiative
• 5 Acute Care Workstreams: Critical Care, General Ward, Periop, Leadership, Medicines
2005
2007
2008 2009 2010 2011 2012
2013
2014
Beyond
Patient Safety in Context
• 7 UK NHS organisations
• Failure rates (13-19%)
• Wide variation in reliability
• 1 in 5 operations involved wrong, faulty or
missing equipment or staff didn’t know where it
was or how to use it. 50% went well
• Delays and threats to patient safety
http://www.health.org.uk/publications/research_reports/evidence_in_brief.html May 2010
>60% preventable
28% negligence
‘this was not my fault’
Leape L et al. Preventing medical injury. Quality Review Bulletin, 1993,8:144-149
We all make mistakes !
Current improvement methods in
healthcare are highly dependent on
from R Resar, Institute for Healthcare Improvement
vigilance and hard work…
All defects in process do not lead
to Institute
bad foroutcomes….
from R Resar,
Healthcare Improvement
Permissive clinical autonomy creates and
allows wide performance margins….
from R Resar, Institute for Healthcare
Improvement
Systemic Migration to Boundaries
INDIVIDUAL BENEFITS
‘
VERY UNSAFE SPACE
Life Pressures
Driving
80 mph –
the
‘illegalillegal’
space
The posted
speed limit
is
50 mphthe ‘legal’
space
Perceived
vulnerability
Belief
Systems.
ACCIDENT
PERFORMANCE
Driving 60
mph- the
‘Illegalnormal’
space (for
almost all of
us!)
Systemic Migration to Boundaries
INDIVIDUAL BENEFITS
‘
VERY UNSAFE SPACE
Life Pressures
Only
wash
hands on
audit
days
Handwashing
– every
patient, every
time
Perceived
vulnerability
Belief
Systems.
ACCIDENT
PERFORMANCE
Handwashing
when patient
has MRSA
Labels of Reliability
For healthcare processes where failure does not
cause immediate catastrophic consequences
• 80% performance lacks consistent clear understanding of
the process (5 front line process users can not easily
articulate the process) - chaotic process
• 95% performance has some variation but 5 front line users
can easily articulate the process
(These are IHI definitions and are not meant to be the true
mathematical equivalent)
Improvement Concepts Associated
with 80-90% Performance
(Primarily can be described as intent, vigilance, and hard work)
• Common equipment, protocols, and written policies/procedures
• Personal check lists
• Feedback of information on compliance
• Suggestions of working harder next time
• Awareness and training
Improvement Concepts Associated
with 95% or Better Performance
(Uses human factors and reliability science to design sophisticated
failure prevention, failure identification, and mitigation)
• Decision aids and reminders built into the system
• Redundant processes utilised
• Habits and patterns known and taken advantage of in the design
• Standardisation of process
Clinical Governance Strategy
2013 – 2016
Adverse event
management
Copies
available
Discuss in your groups an incident that you have been involved in.
Identify things that went wrong in the system due to the way it
was designed or managed.
What improvement concepts could be tested to improve the
reliability gaps that you have identified?
Safety is a moving target
Harm has been defined too
narrowly
Seeing safety through the eyes of
the patient
Consequences for incident
analysis