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re(think)

Patient Safety

Factors affecting safe care-how can we be the safest healthcare system in the world?

Suzette Woodward

National Campaign Director Sign up to Safety

2 Where are you?

Galvanise the field to move forward over the next fifteen years with a unified view

of the future of patient safety

to create a world where patients and those who care for them are free from

avoidable harm’

Tejal Gandhi CEO

National Patient Safety Foundation US February 2015

If you ruled the world of patient safety?

What keeps you awake at night?

What frustrate you?

What would you like to change?

What would you do differently for the next

15 years

3 things

1. How are we learning

2. What is the right culture for safety

3. Are we implementing the right solutions

Kaveh G Shojania Director, Centre for Quality Improvement and

Patient Safety, University of Toronto

Patient Safety after 15 years:

Disappointments, Successes, and What's on the Horizon (May 27, 2015)

http://www.pipsqc.org/BLOGEVENTS/PIPSQCSpotlight/tabid/79/EntryId/91/CAPHC-Webinar-Patient-Safety-

after-15-years-Disappointments-Successes-and-Whats-on-the-Horizon-May-27-2015.aspx

“Incident reporting is the single biggest waste of time in the last

15 years”

Kaveh G Shojania Director, Centre for Quality Improvement and Patient Safety,

University of Toronto

“Incident reporting … is the most mistranslated intervention from

aviation”

Rare Unique

Share across NHS

quickly

• Focus on pie charts and trend data

• Celebrate the numbers going up

• Investigate the wrong things

F

Root cause analysis

• Poor recall

• Months to find out the answer

• Outcome, hindsight and confirmative bias

• Superficial recommendations

• Erosion of practice over time

Response

Produce a new protocol

Tell people off

Send them off for training

Restrict practice or suspension

Optimum time for learning

Incident 24 hours RCA

Are we counting? or

Are we learning?

What would you do differently

?

Clever counting

• Thanks to Tom Downes (via @sheffielddoc Twitter) and IHI

RE(think) reporting and investigation

• Two stage reporting – Triage – Rapid response team

• Case note review

• Safety huddles or briefing and de-briefing – real

time learning

• Automation and apps

3 things

1. How are we learning

2. What is the right culture for safety

3. Are we implementing the right solutions

“The single greatest impediment to error prevention is that we punish

people for making mistakes”

Dr Lucian Leape

12 October 1997

I messed up, I’ve been giving calcium chloride for years.

I was talking to someone while drawing it up.

I miscalculated in my head

I will be more careful in the future

3 things we should all agree on

• The best people can make the worst mistake

• Systems will never be perfect

• Humans will never be perfect

Expect

• Expect to administer ten times the dose

• Expect to operate on the wrong leg

• Expect to ….

• A preoccupation with failure rather than counting where we have failed

avoidable versus unavoidable

• Are you really listening or are you just waiting your turn to talk?

– Quote: Robert Montgomery

Don’t bring me problems

bring me solutions

The right culture is one that combines

• Just culture

• Continual learning

• Design

• Procurement

• Resilience

– so we are adaptable and prevent the little things getting bigger

Just culture

• People who make an error (human error) are cared for and supported

• People who don't adhere to policies (risky behaviour) are asked first before being judged

• People who intentionally put their patients or themselves at risk (reckless behaviour) are accountable for their actions

Re(think) Human Resource Policies

Human error

• Comfort, support, console

Risky

behaviour • Seek to understand why

Reckless behaviour

• Discipline

3 things

1. How are we learning

2. What is the right culture for safety

3. Are we implementing the right solutions

Theory Gap

10-17 years

Practice

Successful adoption of interventions requires us to know why and how

they work

Science of implementation

Implementation Science – and open access on line journal via

http://www.implementationscience.com/

Great I am not alone!

‘The problem with…’

• A new series in BMJ Quality and Safety

– Covers pervasive problems that seem to resist solution

• Kaveh Shojania and Ken Catchpole

• http://qualitysafety.bmj.com/

The problem with solutions

• Focusing on a problem out of proportion to its importance

• Failing to appreciate the complexity of a problem

• Strategies that sound like solutions but still haven't been worked out, so are really unsolved problems – e.g. change the culture, sort out team work

The problem with implementation

• The intervention may commonly be implemented inadequately

• The intervention requires much more effort or expertise than generally recognised

• We convince ourselves to keep carrying on when the solution may not be the right one

• The solution can work, but frequently fails to deliver in practice

‘The problem with..’ checklists

Ken Catchpole and Stephanie Russ

Competing priorities

Five common causal factors

Information Communication

Observation Design

Relationships

Human factors

Mental workload

Fatigue Boredom Scheduling

Barriers Rules Distractions The physical environment

Physical demands

Device/product design

Teamwork Process design

Abbreviations Assessment

Are we standardising where we can?

Mary Dixon Woods Webinar for HIS QI Connect June 2015

Are we designing out error?

Thanks to Ross Scrivener @Scr1v via twitter

RE(think) solutions

Reducing harm topic by topic

Relentless focus on the cross cutting

factors

Design out error Procure the same things across the

NHS

Standardise equipment, care processes, reduce

handovers and reduce waste

Our promise

1. Learning and sharing

2. Culture and mindset

3. Create new knowledge around the persistent problems that seem to resist solution

Stopping or doing things in a very different way always sounds like such a

big deal

It sounds like something that should be approached in awe and done once or

twice in a lifetime

We fear it will make us look stupid

I would argue otherwise stopping or re(thinking) patient

safety could be a very wise thing to do

Top sites for more information • NHS Scotland, Quality Improvement Hub (Qihub) via http://www.qihub.scot.nhs.uk [this one

has a whole section on quality and efficiency supporting the business case for safety]

• Agency for Healthcare Research and Quality (AHRQ) in the US via http://www.ahrq.gov

• Risky Business site for all past talks via http://www.risky-business.com/

• BMJ Open – open access online journal via http://bmjopen.bmj.com/

• BMJ blogs via http://blogs.bmj.com/quality/

• Health Quality and Safety Commission New Zealand via http://www.hqsc.govt.nz/ which also has the Open campaign via http://www.open.hqsc.govt.nz/

• The Health Foundation and their patient safety resource centre via http://patientsafety.health.org.uk/

• The National Patient Safety Foundation in the US via http://www.npsf.org/

• IHI – the institute for healthcare improvement via http://www.ihi.org/

• NPSA for archived stuff via http://www.npsa.nhs.uk/

• WHO patient safety via http://www.who.int/patientsafety/en/

• Leading health Systems Network via http://www.leadinghealthsystemsnetwork.org/

• WISH – World Innovation Summit for Health via http://www.wish-qatar.org/

re(think)

Patient Safety now!

Suzette Woodward National Campaign Director Sign up to Safety