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The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr...
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Building an Irish Network of Quality Improvers QI TALK TIME The Science of Patient Safety – Dr John Fitzsimons 22 nd February 2017 1-2 pm Connect Improve Innovate The Science of Patient Safety – Dr John Fitzsimons 22 nd February 2017 1-2 pm
Transcript of The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr...
Building an Irish Network of Quality Improvers
QI TALK TIME
The Science of Patient Safety – Dr John Fitzsimons 22nd February 2017 1-2 pm
Connect Improve Innovate
The Science of Patient Safety – Dr John Fitzsimons 22nd February 2017 1-2 pm
Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes
Hospital, Drogheda and Clinical Director with the HSE QID. He trained in paediatrics in Ireland, Australia and the UK.
• John trained as a Patient Safety Officer with the Institute of Healthcare Improvement (IHI) in 2009 and became a fellow of the Improvement Faculty at the NHS Institute for Improvement & Innovation for two years.
• In September 2013 he commenced a half-time secondment as Clinical Director for Quality Improvement with QID.
• He was chair of the group that published the NCEC Paediatric Early Warning System Guideline in 2015.
• He is a course co-director for the HSE/RCPI Diploma in Leadership and Quality in Healthcare.
Dr John Fitzsimons
• Interactive
• Sound
• Chat box function • Comments • Questions • Ideas
• Q&A at the end
• Attendance certs
Tips for successful webex
Building an Irish Network of Quality Improvers
QI TALK TIME
The Science of Patient Safety – Dr John Fitzsimons 22nd February 2017 1-2 pm
Connect Improve Innovate
The Science of Patient Safety
Outcomes At the end of this webinar you will be able to…
• Describe the evolution of patient safety as a science
• Discuss new ideas in patient safety including HRO’s, human factors, safety culture & Safety II.
• Apply methods to improve measure and monitor safety in your work place
Is patient safety a science?
Organisational Safety
© Erik Hollnagel, 2009
IT Revolut ion
Three ages of indust rial safet y
2000195019001850
1931Indust rial accident
prevent ion
1893Railroad Safet y Appliance Act
1769Indust rial Revolut ion
1961Fault t ree analysis
Age of t echnology
1979Three Mile
Island
Age of human fact ors
2003Columbia
Age of safet y managementThin g s c an g o Th in g s c an g o
w r o n g bec ause w r o n g bec ause Or gan isat io n s f ailO r gan isat io n s f ail
2009 AF 447
State of the art: Patient Safety 2013
Shekelle PG et al. Annals of Internal Medicine. 2013 Mar;158(5_Part_2):365-368.
A new idea?
Kieran Walsh. International Journal for Quality in Health Care 2009; Volume 21, Number 3: pp. 153–159
First, do no harm! Hippocrates, c. 460 – c. 370 BC
Harvard Medical Practice Study NEJM 1991
IOM Reports
To Err is Human
1999
Crossing the Quality Chasm
2001
A Way to Patient Safety
Building a Culture of Patient Safety 2008
A Vision for Patient Safety
“Knowledgeable patients receiving safe and effective care from skilled professionals in appropriate environments with assessed outcomes”
Irish National Adverse Events Study Rafter et al. BMJ Qual Saf. 2016 Feb 9.
What is patient safety?
“The avoidance, prevention and amelioration of adverse
outcomes or injuries stemming from the process of
healthcare”
Charles Vincent
Error & Harm
Error (commission & omission)
• Slips
• Lapses
• Mistakes
Harm
Error
“…a generic term to encompass all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency.”
Dr. James Reason
Harm
“An injury arising from the process of healthcare that you would not wish to happen to you or a loved one”
Categorising Harm
Category A Error potential
Category B to D Error no harm
Category E to H Harm occurs with increasing injury & need for intervention
Category I Death
Error & Harm
Error
Harm
Non-preventable
Preventable
So, who is responsible?
A Systems Perspective
“ Rather than being the main instigators of
an accident, operators tend to be the
inheritors of system defects…..
their part is that of adding the final garnish
to a lethal brew that has been long in the
cooking.”
James Reason
Patient safety view of systems
Environment
Organisation
Practitioners & Patients
Tools & Technology
Tasks
Thanks to Matt Scanlon
Swiss Cheese Model
James Reason
Organisational Accident Model
Harm
Management decisions
& Organisational
processes
Environment factors
Team factors
Staff factors
Task factors
Patient factors
Unsafe acts
Errors
Violations
Organisation & Culture
Contributory factors
Care delivery problems
Defences & Barriers
Latent failures
Active failures
Adapted from Charles Vincent
Safety Solutions
“We cannot change the human condition, but we can change the conditions under which humans work”
James Reason
Innovation in Patient Safety https://hbr.org/2016/08/the-next-wave-of-hospital-innovation-to-make-patients-safer
Safety Solutions Engineering & System
Leadership, Risk Management &
Organisational Culture
Design, redesign & improvement
- Technology
- Standardisation
- Bundles
- Checklists
- Forcing functions
- Redundancies
Innovation in Patient Safety https://hbr.org/2016/08/the-next-wave-of-hospital-innovation-to-make-patients-safer
Why don’t they just do it like we told them?
Work as imagined Vs. Work as is
Violations
• Routine
• Necessary
• Optimising to reckless
PERFORMANCE
ACCIDENT
Systemic Migration to Boundaries
VE
RY
UN
SA
FE
SPA
CE
The posted
speed limit
is
50 mph- the
‘legal’
space
Belief
Systems.
Life Pressures
INDIVIDUAL BENEFITS
Driving 60
mph- the
‘Illegal-
normal’
space
Driving
80 mph –
the
‘illegal-
illegal’
space (for
almost all
of us!) Perceived
vulnerability
R. Almaberti
PERFORMANCE
ACCIDENT
Systemic Migration to Boundaries
VE
RY
UN
SA
FE
SPA
CE
Handwashing,
every patient,
every time
Belief
Systems.
Life Pressures
INDIVIDUAL BENEFITS
Hand
washing
when patient
has MRSA
Only
wash
hands on
audit
days
Perceived
vulnerability
R. Almaberti
Human Factors
Acnordicg to resraech at Cambrdige Unrveisity, it deosn't mettar in waht oedrr the lertets in a wrod are. The olny ipmortant tihng is taht the fisrt and lsat letter be in the rgiht palce.
The rset can be a tatol mses and you can slitl raed it withuot prlboem. Tihs is becuase the huamn mnid deos not raed eevry letter by itslef, but the wrod as a whloe.
The Human Factor
• We learn from recognising our errors
• We have good days & bad days
• We get tired, sore and sick
• We have cognitive limitations
• We don’t always say what we mean
• We have lives outside of work
Cognitive Error
Dual process model for decision making.
Croskerry P et al. BMJ Qual Saf doi:10.1136/bmjqs-2012-
001712
Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.
Reducing Cognitive Error
• Enhance knowledge and awareness of cognitive biases
• Enhance professional reasoning, critical thinking and decision-making skills
• Enhance work system conditions, workflow design that affect cognition
Human Factors Solutions
• HALT - Hungry
- Angry
- Late
- Tired
• Sterile Cockpit
Theory of High Reliability
Sutcliffe KM, Paine L, Pronovost PJ
Re-examining high reliability: actively organising for safety
BMJ Qual Saf Published Online First:21 March 2016. doi: 10.1136/bmjqs-2015-004698
High Reliability Organisations 5 key Features
• Preoccupation with failure
• Reluctance to simplify
• Deference to expertise
• Sensitivity to operations
• Resilience
Team Learning
After Action Review
1. What was expected to happen?
2. What actually happened?
3. Why was there a difference?
4. What can we learn to improve?
High Reliability Organisations 5 key Features
• Preoccupation with failure
• Reluctance to simplify
• Deference to expertise
• Sensitivity to operations
• Resilience
Paediatric Early Warning System
Team work & Communication
Decision & Response support
Situation Awareness
Family Involvement
PEWS observation
chart & score
High Reliability Organisations 5 key Features
• Preoccupation with failure
• Reluctance to simplify
• Deference to expertise
• Sensitivity to operations
• Resilience
Simulation
Simulation
High Reliability Organisations 5 key Features
• Preoccupation with failure
• Reluctance to simplify
• Deference to expertise
• Sensitivity to operations
• Resilience
What is Situation Awareness?
The ”It” Factor
Situation Awareness
Perception Gather the information
Comprehension Recognise and Understand
Projection Anticipate/Predict/Mitigate/Escalate
Situation Awareness Tools Safety Pause ISBAR for Clinical Handover
A serious safety event has occurred.
Click here for details.
With thanks to Stephen Meuthing CCHMC
High Reliability Organisations 5 key Features
• Preoccupation with failure
• Reluctance to simplify
• Deference to expertise
• Sensitivity to operations
• Resilience
Great Teams Rescue
J Thorac Cardiovasc Surg. 2000 Apr;119(4 Pt 1):661-72.Human factors and cardiac surgery: a multicenter study.de Leval MR(1), Carthey J, Wright DJ, Farewell VT, Reason JT.
Amir A. Ghaferi, M.D., John D. Birkmeyer, M.D., and Justin B. Dimick, H. N Engl J Med 2009; 361:1368-1375October 1, 2009
Safety I & Safety II
Safety II
“Safety is the ability to succeed under varying conditions”
Eric Holnagel
Learning from Excellence @adrianplunkett
Learning from Excellence Start-up Guide http://learningfromexcellence.com/resources/
Safety Solutions Engineering & System Behaviours
Leadership, Risk Management &
Organisational Culture
Design, redesign & improvement
- Technology
- Standardisation
- Bundles
- Checklists
- Forcing functions
- Redundancies
Understand the work
Human factors
- Communication
- Physical limitations
- Cognitive
High Reliability Organising
- Team Attitude & Team Work
- Practice & Simulation
- Situation awareness
- Include patients & families
Becoming safe
Safety is a Choice
Will
Ideas
Execution
Berwick Report
Importance of Culture
‘In the end, culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime.’
Berwick Review, 2013, (p.11)1
A Safe Culture
Learning culture
Just culture Reporting
culture
Manchester Patient Safety Framework (MaPSaF)
Safety Culture Maturity
Pathological
Reactive
Calculative
Proactive
Generative
The Origins of Patient Safety
Fitzsimons J. Vaughan D. Top 10 interventions in Paediatric Patient Safety. Curr Treat Options Peds (2015) 1:275–285
Measuring Safety First Do: Know Harm!
• Incident reporting
- Healthcare staff
- Parents and families (different from complaints)
• Serious Incident review & Root cause analysis
• Trigger Tools
• HSMR
Trigger Tools
Trigger Tools
A framework for measuring and monitoring safety Charles Vincent et al Health Foundation 2014
A framework for measuring and monitoring safety Charles Vincent, Health Foundation 2014
A framework for measuring and monitoring safety Charles Vincent Health Foundation 2014
State of the art: Patient Safety 2013
Shekelle PG et al. Annals of Internal Medicine. 2013 Mar;158(5_Part_2):365-368.
Irish Patient Safety Resources www.hse.ie/eng/about/Who/qualityandpatientsafety/
Quality & Safety Walkabouts Safety Pause
Irish Patient Safety Resources NCEC Guidelines for Patient Safety
A Challenge!
“When as kids we came to an orchard wall that seemed too high to climb, we took off our caps and tossed them over the wall, and then we had no choice but to follow them. I had tossed my cap over the wall of life, and I knew I must follow it, wherever it had fallen.”
An Only Child
Frank O'Connor
Resources
Ireland
• HSE Quality Improvement Division
• National Committee for Clinical Effectiveness
UK & International
• Health foundation www.health.org.uk
• Berwick Review into Patient Safety
• Institute for Healthcare Improvement www.ihi.org
• Clinical Human Factors Group www.chfg.org
• Agency for Healthcare Research & Quality www.ahrq.gov
• Lucian Leape Institute
Innovation in Patient Safety https://hbr.org/2016/08/the-next-wave-of-hospital-innovation-to-make-patients-safer
Knowing your system
PEWS – Listening to You Children & families as part of the safety system
Creating a Culture of Excellence
Common Cognitive Errors
Improving Diagnosis in Health Care
National Academies of Sciences, Engineering, and Medicine. 2015.
Improving diagnosis in health care. Washington, DC: The National
Academies Press.
“Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions”
National Academies of Sciences, Engineering, and Medicine. 2015.
Improving diagnosis in health care. Washington, DC: The National
Academies Press.
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