Adverse events In Healthcare Flashcards
What is an adverse event?
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
Some examples
Wrong site surgery Medication errors Pressure ulcers Wrong diagnosis Failure to treat Patient fall Hospital acquired infection Medicine adverse effects ( side effects )
Drug safety - side effects
- 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
An example …
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 )
Consequences of patient harm
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
Who do we know if a hospital is safe ?
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
Hospital SMRs are not fit for purpose
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
What % of hospital deaths is avoidable
3.6%
Study of 100 randomly selected deaths in each of 34 randomly selected hospitals
5 contributory factors per case
Hogan et al
Why is there harm ?
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
Swiss cheese model - why adverse events occur
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
Active failures
Unsafe acts committed by people in direct contact with patient Types Errors - Knowledge - rules - skills
Violations
Errors - knowledge based
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
Errors - rule based
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
Errors - skills based
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
Violation - people intentionally break the rules
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
Latent conditions ( latent error )
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
The importance of culture
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
Human factors in health care
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
Human factors approach
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
Situations associated with an increased risk of error
Unfamiliarity with the task Inexperience Shortage of time Inadequate checking Poor procedures Poor human equipment interface
Patient safety
Coordinated efforts to prevent harm occurring to patients causes by the process of health care itself
Apply human factors thinking to the work environment
Avoid reliance on memory Make things visible Review and simplify processes Standardise common processed and procedures Routinely use checklists Decrease reliance on vigilance
NHS organisations should be
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
What to do if an adverse event occurs ?
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
Improve patient safety
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
