ASBHDS III - Session 2 - Lecture 1 - Systems Approach Flashcards
1 - Title
Quality and Safety in Healthcare:
Systems Approach to Patient Safety and Root Cause Analysis
“Set out the issues regarding pt safety, how to approach it from a systems point of view, how to look at it from a quality improvement perspective which builds on a systems POV and specific techniques (2 in this lectue, lecture this afternoon is general perspective i.e. where they came from) but don’t in any way imagine that these are the only tekkers available – a lot of work has gone into understanding how we improve systems including quality an safety – pretty much all of it from outside medicine – import in our understanding from other industries, bc we don’t make cars or fly planes, does not mean the lessons they learnt do not apply to us.”
2 - Objectives
Objectives
• Understand healthcare as a complex sociotechnical system
• Understand how errors occur in healthcare using Reason’s Swiss Cheese Model
• Appreciate the burden of medical errors in healthcare
• Appreciate the importance of incident reporting
• Describe incident investigation using currently applied methods of Root Cause Analysis
• Understand what is meant by a Systems Approach to patient safety
• Critically assess the benefits and challenges of currently applied methods of investigating incidents in healthcare
“1. Healthcare not a single entity, has both social (how people work) and technical aspects (using tools e.g. fishbone tool) to it, and failing to understand both perspectives, you’re doomed to failure. Looking at factors alone fails - only when 2 are used together that the 2 works – to do with human factors, mngmt, leadership.
- what is the level of burden we have with medical errors
- why we place a lot on incident reporting
- why we place a lot in understanding root causes of it
- what are the possible options regarding the various methods.”
3 - Prof Charles Vincent
“A history of medicine as harm, rather than benefit, could easily be written; a one-sided, incomplete history to be sure, but a feasible proposition nonetheless.” (Prof Charles Vincent)
[IMG Patient Safety book]
“Charles Vincent - guru of safety and healthcare – he should be the guy doing this lecture. Statement made from the perspective that we believe, as drs that we only do good. He’s a dr himself, he would happily tell you – if we just change our perspective a bit, and think how much harm am I doing today, and just then, for that moment, you might start thinking, how can we make things better? Instead of thinking I’m a human, I do good things, I don’t need to improve etc. etc. but if we actually think about where we are and what we do in terms of how much harm we do we might actually strive to do things better rather than accept the status quo [existing state of affairs]”
4 - Why did Jack Adcock die?
Why did Jack Adcock die?
“[Video] He grew into an energetic and popular little boy, after 6 yrs old he died in hosp after medical staff were told not to rescuscitate him. Needless death after admitted with D&V, Theresa Taylor sister on trial for gross negligence, Portuguese nurse Isabel Amaro – the court has Jack admitted to hospital just before 18th feb 2011 on request of GP, it wasn’t until almost 6 hrs later they realised he had infection. Transferred to another word with little way of handing open. It was shortly after that Dr BG saw him under cardiac arrest – she later admits she mixed him up with another child who was d/c home, resuscitation efforts, too ill to be revived, defendants been charged with gross negligence manslaughter.
Transformed UHL attitude to pt safety, it also transformed the medical professions understanding for systems – for the first time a doctor was up for gross negligence – sis TT was found not guilty, IA on there too. A lot of drs were incredibly unhappy and in fact crowd sourced an appeal against Dr BG from the med reg, that appeal has won through”
https://www.youtube.com/watch?v=WLK-K_kQJtM
5 - Healthcare as a complex sociotechnical system
Healthcare as a complex sociotechnical system
CULTURE POLICIES GOALS LEGAL CONTEXT FINANCIAL CONTEXT - Knowledge - Ward environment - Technology --- Eprescribing --- CDSS --- Electronic records - Equipment
“Why Dr BG found herself at the wrong end of a criminal court case, not even a civil court case, a crim court case was a thing that the medi profession found difficult to square. For some people they feel the medi profession had the arrogance to believe they’re above the law and I think JA’s parents believed that and pursued it and kept pursuing it. For others, it’s a failure of Med profession to see what a system is. Changing a system is so much hard work. And that’s a stance that a lot of drs take. I think that is now starting to change. Ppl are realising that it isn’t just their livelihood, their freedom – she got a suspended sentence, is at stake, if they don’t change the system. But to do that you have to take on the culture, the hierarchy that we have and created for ourselves – address policies both political and managerial, diff goals we have between resources and finance, legal context and the financial context in which we operate – it means you have to go outside the consulting room, outpt clinic, ward, operating theatre.”
CDSS = clinical decision support system
6 - Human Error
Human Error
• Error as a social fact of life
• 4 sub-categories of error:
– Slips (commission): Failures of attention
– Lapses (omission): Failures of memory
– Mistakes: Rule based or knowledge based
– Violations
“So let’s start with some facts. Fact #1 = Error is part of life. Let’s just accept that as standard. So it’s not the matter of whether you’re going to make an error - you are going to make an error, it’s the matter of understanding how that error becomes a focus
In case of Jack Adcock
1. i.e. you slipped, made a mistake - [6+ hr delay before realising Adcock was septic]
2. where you forgot to do something, a lapse - [failing to check identify, thinking Adcock was other child who was DNR due to association of bed condition (she thought he was the previous 2 y/o pt in that bed who had been D/C)]
3. error that was a mistake, where you deviated from the rule or knowledge based that determined where you should be headed towards [mistake from ascertainment on whether he was septic - was to assume that the paramedic report was correct, stating he had diarrhoea not sepsis]
4. more so than mistakes the final one is violation of rule or knowledge (a more determined mistake) - [reason Dr BG was found guilty of manslaughter with negligence was that she violated several clin care aspects to it – effectively as failing to recognise the significance of lactate - between the difference of lactate between the anion large and small amounts bicarb – should’ve recognised that that degree of lactate was significant, assumed he was getting better
why Nurse Amaro failed to monitor Jack, assumed it was a bit of diarrhoea as well]
So pretty much all the errors occurred there. But the question is – is it right to blame just Dr Bawa-Garba and Theresa Taylor (Ward Sister), and not LRI as a whole? Many think this is wrong …”
7 - The Swiss Cheese Model
KEY CONCEPTS:
Latent conditions
Active failures (Unsafe Acts)
Multiple defences (Defences in Depth)
https://www.youtube.com/watch?v=twsA3z3xFVE
Reason J. Human error: Models and management. BMJ 2000 Mar 18; 320(7237): 768-70.
https://doi.org/10.1136/bmj.320.7237.768
“Unsafe acts take place all the time – remember what I said – error is part of life. The issue is when you make that unsafe act you don’t know what just happened behind you, and the preconditions have lined up that with supervision and organisational failures that it just went wrong. Many times you will get away with unsafe acts bc it won’t line up – this is known multiple defences line - but when they do, it leads to the Swiss Cheese Model of error.”
8 - Latent Conditions and Active Failures
Latent Conditions and Active Failures
[flow chart]
“Most of you will be focused on, decision errors = some of you will be based on skill-based errors. Perceptual errors is basically how you perceive things, the psychology of looking at things. And violations are things around care pathways and procedures that you should be doing. But we are trying to introduce you to environmental factors, and mental factors such as how you feel and how you feel you think you are ready – e.g. GW get 4 pts to surgery – some people decided in the break to go for a coffee break – which is fine – as this this optimised physiological state. Adverse mental state/physiological state could mean you need to take a break, but then taking a break could sacrifice optimising environmental factors by understanding the physical and technological environment needed around you, and so on. So you need to understand the task, so you won’t get all 3 preconditions as lined up as perfect – you will end up sacrificing one to get the nature of thre other 2. Unsafe supervision is basically the education part, the training part – were you trained to actually do those things that you were asked to do, and were problems corrected to actually get those done. And the one at the top end was culture, climate of the organisation, process right, resource management right, I was aware at the time of that incident and now I can declare it bc it was in public domain – Dr Bawa Garba long form – v long website describing situation at LRI – paediatric cultural issues. Dr Andrew Holton – paediatric consultant at LRI, he was deemed to be good for neurology, he was the only paediatric neurologist, overdiagnosed to 700 children, so investigation and compensation had to be paid – same dpt as Dr BG – so same cultural issues were not addressed and the furore of Dr GB did they address them, and that was for decades.”
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