Adverse events In Healthcare

Question 1

What is an adverse event?

Answer 1

An unintended event resulting from clinical care and causing patent harm

Near miss
- a situation in which events or omissions arising during clinical care fail to develop further whether or not as the result of compensating action , thus preventing injury to a patient

Question 2

Some examples

Answer 2

Wrong site surgery 
Medication errors 
Pressure ulcers 
Wrong diagnosis
Failure to treat 
Patient fall 
Hospital acquired infection 
Medicine adverse effects ( side effects )

Question 3

Drug safety - side effects

Answer 3

• a known effect other than that primarily intended relating to the pharmacological properties of the medication
• can cause harm arising from justified action
• balance of risks and benefits need to be shared with patients
• different from medication errors

Question 4

An example …

Answer 4

Gentamicin for early onset neonatal bacterial infection - Adam Scott
Side effects - renal damage and hearing loss
507 patients safety incidents in 2008/2009 relating to the use of the intravenous antibiotic

Blood conc must be kept within the therapeutic range ( give at right time and measure blood level )

Question 5

Consequences of patient harm

Answer 5

Estimated 850,000 adverse events each year in NHS hospital sector

£2 billion direct cost in additional hospital days

11,000 patients lodged new clinical claims during 2015/16

The NHS England paid out £1.4 Bn in 2014/15 to patient and 1/3 lawyers

Berwick and Keogh reports on patient safety network

Question 6

Who do we know if a hospital is safe ?

Answer 6

Hospital mortality data

Data on other measures of safety

• reports of never events and serious incidents
• NHS safety thermometer
• patient safety dashboards

Monitoring and inspections by regulators

• care quality commits (CQC)
• NHS improvement

Question 7

Hospital SMRs are not fit for purpose

Answer 7

Mistaken concept

Dependent on non hospital care e.g variations in planned place of death

Data vagaries e.g definitions /coding

Choice of case mix adjustment model

Relationship with quality of care ( validity) not been demonstrated - not validated as a screening instrument

Question 8

What % of hospital deaths is avoidable

Answer 8

3.6%

Study of 100 randomly selected deaths in each of 34 randomly selected hospitals

5 contributory factors per case

Hogan et al

Question 9

Why is there harm ?

Answer 9

Simplistic interpretations of safety consider harm to be the result of incompetence and negligence

We need a better understanding of the factors underlying adverse outcomes

Question 10

Swiss cheese model - why adverse events occur

Answer 10

Latent failures such as management decisions and organisational processes

Conditions of work ( current ) - background factors , workload , supervision, communication, equipment, knowledge : ability

Active failures - unsafe acts- omissions , action slips / failures , cognitive failures ( memory lapses and mistakes ) , violation

Barriers and defences

Accident

Question 11

Active failures

Answer 11

Unsafe acts committed by people in direct contact with patient 
Types 
Errors
- Knowledge 
- rules 
- skills 

Violations

Question 12

Errors - knowledge based

Answer 12

Forming wrong plans as the result of inadequate Knowledge or experience

I.e a junior doctor misdiagnosing meningitis in child as has no experience in paediatrics or A+E

Question 13

Errors - rule based

Answer 13

Encounter relatively familiar problem but apply wrong rule ( misapplication of a good rule of application of a bad rule

E.g a nurse followed treatment regimen for a 10-15 yr old on a child 10 and small for his age leading to child receiving effective overdose of medication and suffering an adverse effect

Question 14

Errors - skills based

Answer 14

Attentions slips and memory lapses . Involves the unintended deviation of actions from what may have been a good plan

E.g a pharmacist interrupted by a assistant when preparing for antibiotic suspension and forgets to add right amount of water to powder as conc was lost

Question 15

Violation - people intentionally break the rules

Answer 15

Routine a violation that has become normal within a peer group

Situational context dependent - time pressure , lack of supervision, low staffing

Reasoned - deliberate deviation from protocol thought to be in patients best interest at the time

Malicious deliberate act intended to harm

Question 16

Latent conditions ( latent error )

Answer 16

Develop over time and lay dormant until they combine with other factors or active failures to cause an adverse event for example

• working environmental conditions
• training of staff
• sociocultural factors

Question 17

The importance of culture

Answer 17

Blame culture - individuals cover up errors for fear of retribution - reduces focus on true causes of failures

Normalisation of deviance - failings because staff become blind to what is going around them assuming that practices are being tolerated normal - mid staffs

Need a safety culture - a learning culture

Question 18

Human factors in health care

Answer 18

Only relatively recent been acknowledged as an essential part of patient safety

Long recognised in other industries - eg in aviation and nuclear

Major contributor to health care adverse events

All healthcare workers should have a basic understanding of human factors principles

Question 19

Human factors approach

Answer 19

Acknowledges

• universal nature of human fallibility
• inevitablillity of error
• error is not necessarily due to incompetence

Designs things in the workplace to try the minimise the likelihood of error or its consequences

Question 20

Situations associated with an increased risk of error

Answer 20

Unfamiliarity with the task 
Inexperience 
Shortage of time 
Inadequate checking 
Poor procedures
Poor human equipment interface

Question 21

Patient safety

Answer 21

Coordinated efforts to prevent harm occurring to patients causes by the process of health care itself

Question 22

Apply human factors thinking to the work environment

Answer 22

Avoid reliance on memory 
Make things visible 
Review and simplify processes 
Standardise common processed and procedures 
Routinely use checklists 
Decrease reliance on vigilance

Question 23

NHS organisations should be

Answer 23

Promoting a safety culture
Ensuring hand hygiene compliance
Preventing venous thromembolism
Reducing inpatient falls
Reducing pressure ulcers
Reducing urinary catheters use
Optimal use of pre operative checklists
Using real time ultrasound for central line placement
Using central line bundles to prevent infections
Using ventilators bundles to prevent pneumonia

Question 24

What to do if an adverse event occurs ?

Answer 24

Report it ( incident reporting systems)

Assess it seriousness

Analyse why it occurred ( Root cause analysis)

Be open and honest with affected patient and apologise - duty of candour - legal duty

Learn from the event and put in place actions to reduce risk of repeat

Question 25

Improve patient safety

Answer 25

Speak up when things go wrong

Involve patients as partners in their own cafe

Learn from patient and clinical stories

Participate actively in the improvement of systems of care and acquire skills to do so