Learning from incidentsLearning from incidents

Keith ReynoldsKeith Reynolds

Risk ManagerRisk ManagerSouth Warwickshire General Hospitals NHS TrustSouth Warwickshire General Hospitals NHS Trust

IncidentIncident

Unplanned event which resulted or Unplanned event which resulted or had the potential to result in injury, had the potential to result in injury, loss or damageloss or damage

Incident exampleIncident example

In 1998 the patient attended A+E having In 1998 the patient attended A+E having been stung by a wasp. Anaphylactic been stung by a wasp. Anaphylactic shock resulted and she was admitted to shock resulted and she was admitted to hospital for 6 days. One particular hospital for 6 days. One particular symptom was a period of blindness. symptom was a period of blindness. Drugs prescribed include IV adrenaline, Drugs prescribed include IV adrenaline, piriton, maxalon, and cyclizine.piriton, maxalon, and cyclizine.

AllegationsAllegations

A 1mg dose of adrenaline was given in A 1mg dose of adrenaline was given in one shot IV leading to a non-one shot IV leading to a non-haemorrhaging infarct in the brain haemorrhaging infarct in the brain causing ischaemia affectingcausing ischaemia affecting eyesight eyesight and causing amnesia amongst other and causing amnesia amongst other symptoms. Claimant no longer able to symptoms. Claimant no longer able to work.work.

CostCost

This case estimated at £480,000This case estimated at £480,000 Total cases involving the Trust £10 Total cases involving the Trust £10

millionmillion Total cases settled last year in the Total cases settled last year in the

NHS £250 millionNHS £250 million

Incident InvestigationIncident Investigation

““Rather than being the main instigators Rather than being the main instigators of an accident, operators tend to be of an accident, operators tend to be the inheritors of latent failures the inheritors of latent failures created at the blunt end. Their part is created at the blunt end. Their part is usually that of adding the final garnish usually that of adding the final garnish to a brew which has been long in the to a brew which has been long in the cooking.”cooking.”

Reason: Reason: Human Reliability (1988)Human Reliability (1988)

Clinical care

The environment of care

Financial resources

CLINICAL GOVERNANCE

ORGANISATIONAL CONTROLS

FINANCIAL CONTROLS

Organisational Assurances

(Annual Report)

Clinical Assurances (Clinical Governance

Report/Annual Report)

Financial Assurances

(Annual Accounts)

Risk management Risk management and corporate and corporate governancegovernance

National Health Service National Health Service initiativesinitiatives

AS/NZS 4360:1999, Risk ManagementAS/NZS 4360:1999, Risk Management Clinical governanceClinical governance Controls assuranceControls assurance Clinical Negligence Scheme for TrustsClinical Negligence Scheme for Trusts

– risk poolrisk pool– risk management standards with risk management standards with

discountsdiscounts

CLINICAL NEGLIGENCE SCHEME FOR CLINICAL NEGLIGENCE SCHEME FOR TRUSTS - RISK STANDARDSTRUSTS - RISK STANDARDS

Clinical RM strategyClinical RM strategy Defined Board Defined Board

responsibilityresponsibility Clinical RMClinical RM Incident reporting Incident reporting

systemsystem Rapid follow-up of major Rapid follow-up of major

incidentsincidents Complaints managementComplaints management Patient information on Patient information on

risks and benefitsrisks and benefits

Standards for medical Standards for medical record keepingrecord keeping

Induction arrangements Induction arrangements for clinical stafffor clinical staff

Clinical risk Clinical risk management systemmanagement system

Clinical care - guidelines, Clinical care - guidelines, accountability etcaccountability etc

Maternity care standards Maternity care standards for high risk pregnancyfor high risk pregnancy

RM STANDARDS (cont.)RM STANDARDS (cont.)

Standards for medical record Standards for medical record keepingkeeping

InductionInduction Clinical risk management systemClinical risk management system Clinical care - guidelines, Clinical care - guidelines,

accountability etcaccountability etc Maternity careMaternity care

Controls Assurance Controls Assurance standardsstandards

Risk mgt. systemRisk mgt. system Buildings, land,plant and Buildings, land,plant and

non-medical equipmentnon-medical equipment Catering and food Catering and food

hygienehygiene Contracts & control of Contracts & control of

contractorscontractors Emergency preparednessEmergency preparedness Environmental Environmental

managementmanagement Fire safetyFire safety

Health and safety mgt.Health and safety mgt. Human resourcesHuman resources Infection controlInfection control IM&TIM&T Medical devices mgt.Medical devices mgt. Medicines managementMedicines management Professional and product Professional and product

liabilityliability Records managementRecords management SecuritySecurity TransportTransport Waste managementWaste management DecontaminationDecontamination

TM T

Trust Board

C lin icalG overnanceCom m ittee

Contro lsAssuranceCom m ittee

Audit and R iskG roup

D irectorateCorporate

G overnancecom m ittees

Specialist clinicalgovernance committees

Research and ethicscom m ittee

Drug and therapeuticscom m ittee

Practices and procedurescom m ittee

Specia listD irectoratecom m ittees

Specialist controlsassurance committees

Health and Safety com m itteeSecurity groupW aste group

Infection control com m itteeM edical records group

CIPB

Finance and auditcom m ittee

Internal audit

M anagem entassurance

Independentassurance

Corporate GovernanceMay 2000

Everyone makes Everyone makes mistakes…..mistakes…..

0100020003000400050006000

£ millions

1975 1980 1985 1990 1996 2001

Year

Clinical litigation costs in UK

Claims against the NHSClaims against the NHS

Current claims against the NHS - number

16,660

8,300

Current claims against the NHS - cost/ £billions

4

2

Obstetrics Others

Source: NHS Litigation Authority

Obstetric claims against Obstetric claims against the NHSthe NHS

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Cere

bral palsy

Fata

lity

Erbs

palsy

Brain da

mag

e

Unn'sa

ry pain

Other

No.Cost/ £millions

Even locally…….Even locally…….

0

1

2

3

4

5

6

7

Cost

/£m

illio

ns

obs

mid

wif

surg

ort

h

a/e

med en

t

pae

d

gyn

onco

l

vasc

anae

s

ophth

hae

m itu

uro

l

gas

tro

den

t

Speciality

Clinical litigation by speciality SWGH 1990-1999

Even locally…...Even locally…...

05

10152025

No.

a/e

obs

surg

orth

mid

wif

med gyn

ent

paed

opht

h

onco

l

urol

vasc

gast

ro

dent

radi

o

itu

haem

anae

s

Speciality

Clinical litigation cases by speciality SWGH 1990-1999

At every level……..At every level……..

020406080

No.

con

sho

reg

mid

w

stnur

sist

er

lcon

sfgd

sreg

lsho

ther

ap

Occupation

Clinical litigation claims by occupation SWGH 1990-1999

Why did it happen…...Why did it happen…...

0

5

10

15

20

25

30

35

No.

Dia

gnosi

s

Dam

age

Superv

isio

n

Feta

l H

eart

rate

Conse

nt

Follow

-up

a-n

ata

labnorm

ality

Adm

dela

y

Medic

ati

on

Wro

ng s

ite

fore

ign b

ody

Com

pete

nce

Oth

er

Costs of clinical incidentsCosts of clinical incidents

Intangible losses

Hidden

losses

Tangible

losses

Reputation, staff morale,

defensive working

Increasedlengthof stay, delayin treating other

patients

Injury,disease,death,litigation

1

29

300

Source: HSE (1997)

Typical total costs of a Typical total costs of a claimclaim

Lacerations, minor scars---------£0-10kLacerations, minor scars---------£0-10k Missed/delayed fractures--------£10-25kMissed/delayed fractures--------£10-25k Surgery to remove surg. mat.---£25-50kSurgery to remove surg. mat.---£25-50k Damaged organs, footdrop-----£50-100kDamaged organs, footdrop-----£50-100k Fail sterilisation = live birth----£100k-Fail sterilisation = live birth----£100k-

1.13m1.13m Paraplegia, blindness-----------£250-500kParaplegia, blindness-----------£250-500k Quadriplegia, brain damage--£500k-4.5mQuadriplegia, brain damage--£500k-4.5m Death---------------------------------£10-250kDeath---------------------------------£10-250k

Adverse incidentsAdverse incidents

Adverse incidents occur in 10% of Adverse incidents occur in 10% of hospital admissionshospital admissions

37% of these result in disability37% of these result in disability 8% result in death8% result in death

Source: Vincent, Neale and Woloshynowych BMJSource: Vincent, Neale and Woloshynowych BMJ 2001;322:517-519 ( 3 March )2001;322:517-519 ( 3 March )

Comparative SWGH Comparative SWGH figures using UCL studyfigures using UCL study

38,000 in-patient episodes pa 38,000 in-patient episodes pa (including Day Case) of which:(including Day Case) of which:– 3800 inpatient adverse incidents3800 inpatient adverse incidents– 950 moderate or permanent 950 moderate or permanent

impairmentimpairment– 304 deaths304 deaths

Incident investigation Incident investigation findingsfindings

Under-reporting of incidentsUnder-reporting of incidents RecordsRecords

– indecipherableindecipherable– undated/not timedundated/not timed– no authorno author– non-existentnon-existent– no reason for treatment/testno reason for treatment/test

Causes of incidents Causes of incidents (NHSLA)(NHSLA)

Failure to monitor, observe, or actFailure to monitor, observe, or act Delay in diagnosisDelay in diagnosis Incorrect risk assessment (for Incorrect risk assessment (for

example, of suicide or self harm)example, of suicide or self harm) Inadequate handoverInadequate handover Failure to note faulty equipmentFailure to note faulty equipment Failure to carry out preoperative Failure to carry out preoperative

checkschecks

Causes of incidentsCauses of incidents

Not following an agreed protocol Not following an agreed protocol (without clinical justification)(without clinical justification)

Not seeking help when necessaryNot seeking help when necessary Failure to supervise adequately a junior Failure to supervise adequately a junior

member of staffmember of staff Incorrect protocol appliedIncorrect protocol applied Treatment given to incorrect body siteTreatment given to incorrect body site Wrong treatment givenWrong treatment given

IncidentsIncidents

The conjunction of…

Reason, Human Reliability (1989)

Incident InvestigationIncident Investigation

Proximate causesProximate causes Sub-proximate causesSub-proximate causes Root causesRoot causes

Root causes reveal areas which if Root causes reveal areas which if changed reap the greatest benefit.changed reap the greatest benefit.

Incident exampleIncident example

68 year old female patient brought to A/E 68 year old female patient brought to A/E by ambulance with non-descript chest by ambulance with non-descript chest pain. Admitted to a medical ward and pain. Admitted to a medical ward and treated for thrombosis. Heparin written treated for thrombosis. Heparin written up for 24 hour period. Delayed KCCT up for 24 hour period. Delayed KCCT test showed hypersensitivity to test showed hypersensitivity to heparin. Blood not clotting. Patient heparin. Blood not clotting. Patient had lung haemorrhage, subsequently had lung haemorrhage, subsequently arrested and died.arrested and died.

Proximate causesProximate causes Differential diagnosisDifferential diagnosis Patient weakened by morphinePatient weakened by morphine Lung haemorrhageLung haemorrhage Sensitivity to heparinSensitivity to heparin Sensitivity not detectedSensitivity not detected Prolonged use of heparinProlonged use of heparin No protamin administeredNo protamin administered

Sub-Proximate CausesSub-Proximate Causes

KCCT test not carried out in KCCT test not carried out in adequate timeadequate time

Protocol for heparin administration Protocol for heparin administration not followednot followed

Conflicting advice in use of Conflicting advice in use of ProtaminProtamin

Root CausesRoot Causes Procedure for receiving Telephoned lab Procedure for receiving Telephoned lab

results LTAresults LTA Lack of advanced diagnostic servicesLack of advanced diagnostic services Inadequate Portering staff at the weekendInadequate Portering staff at the weekend Procedure for urgent sample test LTAProcedure for urgent sample test LTA Training, supervision and information for Training, supervision and information for

Junior Doctors LTAJunior Doctors LTA Protocol for Protamin not communicatedProtocol for Protamin not communicated

Incident InvestigationIncident Investigation

““Any accident is more Any accident is more tragic if human tragic if human experience is none the experience is none the richer for it.”richer for it.”

A.D. Craven: A.D. Craven: Safety and Accident Prevention in Chemical OperationsSafety and Accident Prevention in Chemical Operations

RecommendationsRecommendations

Review clinical incidentsReview clinical incidents Make accurate, timely, identifiable, Make accurate, timely, identifiable,

legible recordslegible records Review the patient when making Review the patient when making

potentially serious interventionspotentially serious interventions Act within level of competenceAct within level of competence Keep up to dateKeep up to date