Medical Error and Professionalism

7/30/2019 Medical Error and Professionalism

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Medical error andMedical error and

From Swiss Cheese to Open DisclosureFrom Swiss Cheese to Open Disclosure

Dr Rachel ThompsonDr Rachel Thompson

Phase 2Phase 2 20122012

AcknowledgementsAcknowledgements: A/Prof Tony O: A/Prof Tony O SullivanSullivan


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How to define Quality in the health careHow to define Quality in the health care

s stems stem??

The extent to which the properties of a serviceThe extent to which the properties of a service ..(Australian Council on Healthcare Standards (accessed(Australian Council on Healthcare Standards (accessed

. . :. . : p: www.ac s.org.aup: www.ac s.org.au


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TheThe safetysafety of the health care system has been definedof the health care system has been defined

by theby the National Health Performance CommitteeNational Health Performance Committee::

thethe avoidance or reduction to acceptable limits ofavoidance or reduction to acceptable limits ofactual or potential harm from health care managementactual or potential harm from health care management

or e env ronmen n w c ea care sor e env ronmen n w c ea care s e veree vere

AustralianAustralian Council for Safety and Quality in Health CareCouncil for Safety and Quality in Health Care

e n t on:e n t on:

thethe degree to which the potential risk and unintendeddegree to which the potential risk and unintendedresu ts are avoi e orresu ts are avoi e or minimiseminimise


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Measures of health system performance, including:Measures of health system performance, including:

easures o e ec veness, appropr a eness, aneasures o e ec veness, appropr a eness, anefficiencyefficiency

Responsiveness (Open disclosure)Responsiveness (Open disclosure)

Accessibilit Patient involvementAccessibilit Patient involvement

SafetySafety

Continuity, capability and sustainabilityContinuity, capability and sustainability

National Health Performance CommitteeNational Health Performance Committee


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Assessing and monitoring Quality is not simple:Assessing and monitoring Quality is not simple:

Service and clinical erformance indicators e. . seeService and clinical erformance indicators e. . seeNational Report on Health Sector Performance IndicatorsNational Report on Health Sector Performance Indicators20032003))

characteristics that can be compared to benchmarks orcharacteristics that can be compared to benchmarks orclinically defined practicesclinically defined practices

n s o s a s ca n orma on on e sa e y an qua y o ea caren s o s a s ca n orma on on e sa e y an qua y o ea carein Australiain Australia

Links to other Australian statistical information on the safety and quality ofLinks to other Australian statistical information on the safety and quality of

.. But needs reliable reporting systems and a systematic.. But needs reliable reporting systems and a systematicreviewreview


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Why is quality and safetyWhy is quality and safety

important?important?

In Australia, up to 16% of hospital patientsIn Australia, up to 16% of hospital patients

50,000 patients/year suffer permanent disability50,000 patients/year suffer permanent disability

,,

Iatrogenic injuries:Iatrogenic injuries:

resu e rom a a ure o pro ess ona smresu e rom a a ure o pro ess ona sm

Lack of care or attention, failure to request a testLack of care or attention, failure to request a test

Actin on insufficient information la sesActin on insufficient information la ses etcetc

1 % due to lack of knowledge1 % due to lack of knowledge

1. Wilson et al 1995, 163; 458-471, Wilson 1999, M JA 170;411, and Wilson & Van Der Weyden 2005,MJA 182(6); 260-1.


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Medical errorMedical error

more r g en ng ac smore r g en ng ac s

-- o err s uman: u ng a sa er eao err s uman: u ng a sa er easystemsystem::

44,000 to 98,000 people die in US hospitals44,000 to 98,000 people die in US hospitalseach yeareach yeardue to medical errordue to medical error 22

Medication errors (USA) result in 7,000+ deathsMedication errors (USA) result in 7,000+ deaths

alone each yearalone each year 22

2Kohn, K , Corrigan, J, Donaldson M. (1999). To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press


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..Based on data collected over several years fromBased on data collected over several years from

multi le artner institutions IHI estimatesmulti le artner institutions IHI estimatesthat:that:

occur in the US each yearoccur in the US each year a rate of overa rate of over40 000 er da40 000 er da ..

5 million lives Campaign:5 million lives Campaign:. .. .

ampaign.htm?TabId=1ampaign.htm?TabId=1


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nn a verse even sa verse even s an nc en n w c an nc en n w c unintended harm resulted to a person receivingunintended harm resulted to a person receivinghealth care.health care. **

Local events (e.g. North Shore Hospital) revealLocal events (e.g. North Shore Hospital) revealthat we are all susceptible to being involvedthat we are all susceptible to being involved

*Wilson,*Wilson, RuncimanRunciman,, GibberdGibberd. (1995). Quality in Health Care Study.. (1995). Quality in Health Care Study. Medical Journal of Australia,Medical Journal of Australia, 163(9),163(9),458458--471.471.


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The financial cost is huge:The financial cost is huge:

USA $37.6 billion each yearUSA $37.6 billion each year22

In Australia the total health care bud etIn Australia the total health care bud etwas>$50 billion (2004) and adverse eventswas>$50 billion (2004) and adverse events

cost us $2 billion =cost us $2 billion = 4%4% of the healthof the healthu ge va ueu ge va ue


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Girl's death triggers NSW health inquiryGirl's death triggers NSW health inquiry

SMHSMH Thursday, 24 January, 2008Thursday, 24 January, 2008

The NSW government has been forced to call anThe NSW government has been forced to call anindependent inquiry into the state's public healthindependent inquiry into the state's public healths stem after a scathin assessment from a coroners stem after a scathin assessment from a coronerinvestigating the death of a Sydney teenager.investigating the death of a Sydney teenager.

Vanessa Anderson 16 died two da s after beinVanessa Anderson 16 died two da s after bein

admitted to Royal North Shore Hospital (RNSH) withadmitted to Royal North Shore Hospital (RNSH) witha skull fracture.a skull fracture.

She had been hit in the head with a golf ball during aShe had been hit in the head with a golf ball during amorning tournament at Asquith in Sydney inmorning tournament at Asquith in Sydney in

http://news.sbs.com.au/worldnewsaustralia/girls_deahttp://news.sbs.com.au/worldnewsaustralia/girls_dea

_ _ _ _ __ _ _ _ _


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Warren AndersonWarren AndersonNov 22 2007 Royal North Shore Hospital Inquiry as noted by the Joint Select Committee hearing on 28 Nov 2007Nov 22 2007 Royal North Shore Hospital Inquiry as noted by the Joint Select Committee hearing on 28 Nov 2007

http://www.parliament.nsw.gov.au/prod/parlment/hansart.nsf/V3Key/LC20071128049http://www.parliament.nsw.gov.au/prod/parlment/hansart.nsf/V3Key/LC20071128049

Vanessa did not die from one person's mistake.Vanessa did not die from one person's mistake.

u yu yat every level in that hospital.at every level in that hospital.

She died because the public hospital system wasShe died because the public hospital system wasnot safe.not safe.

She died because budgets are prioritised overShe died because budgets are prioritised over

patient safety. Two years later, has anythingpatient safety. Two years later, has anythingchanged? We suspect not.changed? We suspect not.

Terms of reference for the NSW public health care system Special Commission of Inquiry:Terms of reference for the NSW public health care system Special Commission of Inquiry:p: www. ea .nsw.gov.au news _ . mp: www. ea .nsw.gov.au news _ . m

codecode


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Launch of windows into safety andLaunch of windows into safety and

qua y n ea carequa y n ea care

http:/ / www.safetyandquality.gov.au/ internet/ safety/ publishing.nsf/ Content/ MediaRelease_2011-10-13_launch_windows_publication


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Does unprofessionalDoes unprofessional behaviourbehaviour in medical schoolin medical school

predict future problems in doctors?predict future problems in doctors?

PapadakisPapadakis(1)(1) -- 70 doctors who had had significant disciplinary70 doctors who had had significant disciplinary

action for unprofessionalaction for unprofessional behaviourbehaviour -- matched to controlsmatched to controls

38% of cases38% of cases vsvs 19% of controls had breaches in professional19% of controls had breaches in professionalbehaviourbehaviour at medical schoolsat medical schools

However, 62% of cases were not identified at medical schoolHowever, 62% of cases were not identified at medical school

19% of controls identified with unprofessionalism at med school19% of controls identified with unprofessionalism at med schoolhad no future problemshad no future problems

Suggests we would need a large intervention or a very targetedSuggests we would need a large intervention or a very targetedcampaign to make useful improvements with the med students whocampaign to make useful improvements with the med students whomi ht have future roblemsmi ht have future roblems

1. Papadakiset al. Academic Medicine 2004;79:244


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Risk factors at medical school forRisk factors at medical school for

su sequen pro ess onasu sequen pro ess ona m scon ucm scon uc

59 doctors identified over 40 years59 doctors identified over 40 years

Compared with 236 controlsCompared with 236 controls

n ngs:n ngs:

Increased riskIncreased risk

Male studentsMale students

Lower socioeconomic statusLower socioeconomic status Failure of early preFailure of early pre--clinical examinationsclinical examinations

1. BMJ 2010: 340: 2040


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Factors contributing to unprofessionalFactors contributing to unprofessional

behaviourbehaviour in doctorsin doctors

696 Canadian physicians who had complaints696 Canadian physicians who had complaintsretained for investi ationretained for investi ation(1)(1)

82 % were due to attitude/communication82 % were due to attitude/communication

Licensing examinationLicensing examination

rom e es commun ca or quar erom e es commun ca or quar e

28 % from the worst communicator quartile28 % from the worst communicator quartile

Males, surgeons and GPs had higher rates ofMales, surgeons and GPs had higher rates ofcomplaintscomplaints

1. Tamblynet al. Academic Medicine 2004;79:244


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Does medical studentDoes medical student behaviourbehaviourr i r l m in h f rr i r l m in h f r

doctor?doctor?

Trends are present between medical studentTrends are present between medical student

BUTBUT

Low predictive valueLow predictive value

alreadyalready

studentsstudents

os s u en s wos s u en s w e av ourae av oura pro ems apro ems auniversity will go on to be good doctorsuniversity will go on to be good doctors


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Professionalism in medicalProfessionalism in medical

studentsstudents

Significant amount of discourse on policies,Significant amount of discourse on policies,

codes and o inion iecescodes and o inion ieces

Research data on professionalResearch data on professional behaviourbehaviour inin11

What aspects of professionalism should beWhat aspects of professionalism should betaug t an assessetaug t an assesse ??

Where do UNSW medical students fit in?Where do UNSW medical students fit in?

1. Morrison, Medical Education 2008:42;118


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Professionalism is comprised of a set of valuesProfessionalism is comprised of a set of values

andand behavioursbehaviours that underpin the social contractthat underpin the social contractetween t e pu ic, me ica pro ession anetween t e pu ic, me ica pro ession an

doctorsdoctors(1)(1)

Major components o pro essiona ism inc u eMajor components o pro essiona ism inc u e

empathy, honesty, patience, teamempathy, honesty, patience, team--mindednessmindedness

u ur yu ur y

1. Irvine 2006, MJA 184;204. 2. Rabinowitz et al. 2004 Med Teach 26;160.


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..

2.2. DemonstratesDemonstrates highhigh ethicalethical andand moralmoral standardsstandards3.3. BehavesBehaves accordingaccording toto anan acceptedaccepted socialsocial contractcontract

4.4. DemonstratesDemonstrates humanistichumanistic valuesvalues suchsuch asas integrityintegrity andandones yones y

5.5. ShowsShows responsibilityresponsibility andand accountabilityaccountability

6.6. HasHas aa commitmentcommitment toto improveimprove

..

8.8. Demonstrates reflective practiceDemonstrates reflective practice

Swick2000. Academic Medicine 75;612.


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How do medical schools ensureHow do medical schools ensure

professionalism in their students?professionalism in their students?

Graduate capability or outcomesGraduate capability or outcomes

e ec on o s u en se ec on o s u en s

Teaching and assessment of personal and professionalTeaching and assessment of personal and professionaleve opmenteve opment

-- written assessmentswritten assessments

-- oral or viva assessmentsoral or viva assessments

--

-- portfoliosportfolios

Fitness to Practice Boards or CommitteesFitness to Practice Boards or Committees

DD b h lb h l


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Doctors canDoctors can t be the onlyt be the onlyr l m ... wh i wr n wi h hr l m ... wh i wr n wi h h

system?system?

Health system prevents honesty andHealth system prevents honesty and

disclosure causin a vicious c cle of re eateddisclosure causin a vicious c cle of re eatederrorserrors

Human errorHuman error

Major inquiries fail to deliver satisfaction toMajor inquiries fail to deliver satisfaction tov c ms or c ange sys ems or preven ur erv c ms or c ange sys ems or preven ur ererrorserrors


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On the wardsOn the wards,, in Specialist Clinics, in Generalin Specialist Clinics, in General

Practice in the communit ..Practice in the communit ..

Discuss with 2 neighbours:Discuss with 2 neighbours:

What have you seenWhat have you seen oror heard?heard?


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Examples of common types ofExamples of common types of

errorserrors

DiagnosticDiagnostic

Error in delay of diagnosisError in delay of diagnosis Wrong or outmoded test etcWrong or outmoded test etc

TreatmentTreatment

Error in operation or procedureError in operation or procedure Error in dose of drug etcError in dose of drug etc

PreventativePreventative

Failure to provide a prophylactic treatmentFailure to provide a prophylactic treatment

OtherOther

Failure in communicationFailure in communication


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Human mistakesHuman mistakes

System ai uresSystem ai ures

Active failuresActive failures == unsafe actsunsafe acts (human)(human)

(within the system)(within the system)


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Active failure:Active failure:

e.g. inaccurate measurement of a dose of ae.g. inaccurate measurement of a dose of adrugdrug

e.g. ordering the incorrect teste.g. ordering the incorrect test

. . u wr. . u wr

happens!)happens!)

Latent condition:Latent condition:

. .. . e.g. inadequate policy on how to deal withe.g. inadequate policy on how to deal with

patients with same namepatients with same name

RR S i ChS i Ch


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ReasonReason s Swiss Cheeses Swiss Cheese

Mo eMo e

Reason, J. BMJ 2000;320:768-770.5


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Cheese slices =Cheese slices = defensive layersdefensive layers within thewithin the

s stem e. . rotectin a ainst:s stem e. . rotectin a ainst: unsafe actsunsafe acts

management deficienciesmanagement deficiencies

psychological precursors to slips /mistakes.psychological precursors to slips /mistakes.

Holes = problems in the system: theHoles = problems in the system: the activeactive


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AAn error occurs only when they all linen error occurs only when they all line upup Accident tra ectorAccident tra ector oror ErrorError


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Problems with this modelProblems with this model

Active errors ma be the dominant roblemActive errors ma be the dominant roblem

Hindsight biasHindsight bias tenuous links seem moretenuous links seem moreimportantimportant

Latent conditions are always present in a systemLatent conditions are always present in a system it is theit is the triggerstriggers for the active failures thatfor the active failures that

..

Latent conditions may not be easily amenableLatent conditions may not be easily amenable

controllablecontrollable


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Active failuresActive failures = mosquitoes can swat them= mosquitoes can swat them

one by one but best to drain the swamps ofone by one but best to drain the swamps oflatent conditionslatent conditions. (Reason). (Reason)

LeapeLeape66::

ssumesssumes uman errors w occuruman errors w occuralter systems to recognise and alter systems to recognise and absorbabsorb

..


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Error managementError management cuts down bothcuts down both activeactive

failuresfailures andand latent conditionslatent conditions

Improving healthcare qualityImproving healthcare quality by improvingby improving, ,, ,

EducationEducation of patients and healthcareof patients and healthcarewor erswor ers

Chan in the cultureChan in the culture from blame andfrom blame andshame to a shame to a justjust blameblame


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Redesigning systems and developing aRedesigning systems and developing a

culture of safetculture of safet

Clinical practice improvement and EBM etc toClinical practice improvement and EBM etc to,,

and efficiencyand efficiency

Patient invo vement citizenPatient invo vement citizen s groups etc ,s groups etc ,issues of equityissues of equity

Clinical governance, accountability, openClinical governance, accountability, opendisclosure, public reportingdisclosure, public reporting

S f d Q lS f d Q l CC


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Safety and QualitySafety and Quality CommissionCommission::. . .. . .

Changes in hospital care systems:Changes in hospital care systems:

Decrease a verse eventsDecrease a verse events

Increased efficiencIncreased efficienc

Increased opennessIncreased openness

Increased awareness of patientsIncreased awareness of patients andand

workersworkers rightsrights Increased satisfaction with care and workIncreased satisfaction with care and work

environmentenvironment

S th l f thS th l f th


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Some other examples of theSome other examples of the

comm ss oncomm ss on s wor suppors wor suppor EvidenceEvidence--based adult general observation chart:based adult general observation chart:

http://www.safetyandquality.gov.au/internet/safety/publishinhttp://www.safetyandquality.gov.au/internet/safety/publishin--. _. _

Patient Identification:Patient Identification:

g.nsf/Content/PriorityProgramg.nsf/Content/PriorityProgram--0404

Medication Safety:Medication Safety:http://www.safetyandquality.gov.au/internet/safety/publishinhttp://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgramg.nsf/Content/PriorityProgram--0606

Clinical Handover:Clinical Handover:http://www.safetyandquality.gov.au/internet/safety/publishinhttp://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgramg.nsf/Content/PriorityProgram--0505

How errors can beHow errors can be


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How errors can beHow errors can be

re ucere uce Improve overaImprove overa Qua ty o CareQua ty o Carehttp://www.ihi.org/IHI/Programs/Campaign/http://www.ihi.org/IHI/Programs/Campaign/

Chan es of racticeChan es of ractice e. . the new standardised drue. . the new standardised drutreatment charts)treatment charts)

Improve standards of serviceImprove standards of service (e.g. medication(e.g. medication

http://www.dva.gov.au/health/provider/pharmacy/medrevu.htmhttp://www.dva.gov.au/health/provider/pharmacy/medrevu.htm

#what#what

. . . .. . . .

RealReal--time auditstime audits

http://www.ahrq.gov/research/nov05/1105RA1.htmhttp://www.ahrq.gov/research/nov05/1105RA1.htm Support and educate doctorsSupport and educate doctors

Educate atients carers and others involved in careEducate atients carers and others involved in carehttp://www.drugdigest.org/DD/SeniorCorner/SrHome/1,10364,,00.htmlhttp://www.drugdigest.org/DD/SeniorCorner/SrHome/1,10364,,00.html


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44 MethodsMethods

--

Root cause analysis (RCA)Root cause analysis (RCA)

Clinical Practice Improvement (CPIClinical Practice Improvement (CPI) and Audit) and Audit

O en DisclosureO en Disclosure

Root ca se anal sis (RCA)Root ca se anal sis (RCA)


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Root cause analysis (RCA) =Root cause analysis (RCA) =

a , ow an w y appenea , ow an w y appene

Focusing on preventionFocusing on prevention

Integrated into health systemIntegrated into health system sentinel events and nearsentinel events and near

Focuses on systems and performance and possible changeFocuses on systems and performance and possible change

xtens ve exam nat on to oo or un er y ng contr ut ngxtens ve exam nat on to oo or un er y ng contr ut ng

factorsfactorsState Govt.s:State Govt.s:

http://www.health.vic.gov.au/clinrisk/sentinel/rca.htmhttp://www.health.vic.gov.au/clinrisk/sentinel/rca.htm

http://www.health.nsw.gov.au/quality/incidentmgt/tools.htmlhttp://www.health.nsw.gov.au/quality/incidentmgt/tools.html

Software:Software: http://www.reason4.com/http://www.reason4.com/


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1.1. Flow diagram of events and timelineFlow diagram of events and timeline

2.2. Identify and examine critical events (following causation rules e.g. causeIdentify and examine critical events (following causation rules e.g. causeand effect chart)and effect chart)

3.3. Identify root causes (evidence) andIdentify root causes (evidence) and categorisecategorise thesethese

4.4. Identify and select solutionsIdentify and select solutions

5.5. Develop recommendationsDevelop recommendations

Clinical PracticeClinical Practice


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Clinical PracticeClinical Practice

mprovemenmprovemen

CPI is the new buzz word in Q&SCPI is the new buzz word in Q&S

Tac es areas o c inica risTac es areas o c inica ris

Aims toAims to accelerateaccelerate im rovement rather thanim rovement rather than

replace system reorganisation etcreplace system reorganisation etc

plus adapted to individuals (personalplus adapted to individuals (personal

ractice im rovementractice im rovement

Based on quality improvement cycleBased on quality improvement cycle


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Setting AimsSetting Aims

What are you trying to accomplish?What are you trying to accomplish? Establishing MeasuresEstablishing Measures

How will you know that a change is anHow will you know that a change is an

Selecting ChangesSelecting Changes

improvement?improvement?

Testin chan esTestin chan es The PlanThe Plan--DoDo--StudyStudy--Act (PDSA)Act (PDSA) CycleCycle


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PIPI f r h r n x r if r h r n x r i

Visit theVisit the Institute for Healthcare ImprovementInstitute for Healthcare Improvement (IHI) for further(IHI) for furtherstudystudy

QMP Exercise:QMP Exercise:

personal improvement practicepersonal improvement practice

(e.g. you may wish to improve a particular area of clinical skill (e.g.(e.g. you may wish to improve a particular area of clinical skill (e.g.cardiovascular examination skill, interpreting an ECG, taking a bloodcardiovascular examination skill, interpreting an ECG, taking a blood

. .. .planning, carrying out and submitting assignments on time)planning, carrying out and submitting assignments on time)

Take this issue / skill for improvement and apply the principles fromTake this issue / skill for improvement and apply the principles from

the IHA site above. Plan and im lement this carefull usin the PDSAthe IHA site above. Plan and im lement this carefull usin the PDSAcycle. Try this out over a reasonable length of time as you need tocycle. Try this out over a reasonable length of time as you need tobe able to try, observe and review the changes that you plan.be able to try, observe and review the changes that you plan.

Write a brief report and peer review this!Write a brief report and peer review this!


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Open, consistent approach to communication withOpen, consistent approach to communication with

patients after an adverse eventpatients after an adverse event Expressing sorrow and regretExpressing sorrow and regret

Maintainin a dialo ue to rovide:Maintainin a dialo ue to rovide: Facts about the eventFacts about the event

Info on ongoing careInfo on ongoing care

Info on steps taken to prevent a recurrence of the errorInfo on steps taken to prevent a recurrence of the error

It is not an acceptance of liability. So advised not to:It is not an acceptance of liability. So advised not to: Speculate or blame othersSpeculate or blame others

B ame yourseB ame yourse

Criticise or comment on matters outside your own experienceCriticise or comment on matters outside your own experience

Admit liabilityAdmit liability

Why promote OpenWhy promote Open


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Why promote OpenWhy promote Open

Disc osure?Disc osure? Patients deserve to expect this level of trustPatients deserve to expect this level of trust

from the health care s stemfrom the health care s stem

Fosters an environment of learningFosters an environment of learning

Accept fallibility of individuals so that systemsAccept fallibility of individuals so that systemscan changecan change (Leape)(Leape)


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Disclosure of information to patients and families isDisclosure of information to patients and families isvital:vital:

TruthTruth

HonestHonest

Respect for patient autonomyRespect for patient autonomy

u w r ru w r r

Health care system based on TRUSTHealth care system based on TRUST

Patients able to make full informed decisionsPatients able to make full informed decisions

Error management of this scenarioError management of this scenario


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Error management of this scenarioError management of this scenario c process o usec process o use

Describe the health care process that the patientDescribe the health care process that the patient

went throu hwent throu h

Identify points where the error(s) may haveIdentify points where the error(s) may haveoccurredoccurred

What are the root causes here (evidence)?What are the root causes here (evidence)?

What could be done to reduce the risk of anotherWhat could be done to reduce the risk of anothererror like this occurring?error like this occurring?

How would you implement changes to preventHow would you implement changes to preventthis from happening?this from happening?


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MP ExerciseMP Exercise Prevention ofPrevention of errorserrors

Take one of the following examples of a health care processTake one of the following examples of a health care processthat has led to an error (or one of your own)that has led to an error (or one of your own)

Dissect t e care an outcomes o t is process. Remem er toDissect t e care an outcomes o t is process. Remem er tostart right at the beginning of the process and analyse everystart right at the beginning of the process and analyse everystep carefully. You may have to fill in the scenario for thestep carefully. You may have to fill in the scenario for thecare that occurs before the error takes lace.care that occurs before the error takes lace.

Analyse this to see what could be changed in the process toAnalyse this to see what could be changed in the process toprevent errorsprevent errors

E x a m p l e s : E x a m p l e s :

Wrong patientWrong patient s blood taken in busy A&E department bys blood taken in busy A&E department by

Wrong limb amputated in a deaf patient who wasWrong limb amputated in a deaf patient who was marked upmarked upby an intern from a different teamby an intern from a different team

The importance of Safety andThe importance of Safety and


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The importance of Safety andThe importance of Safety and

ua y o youua y o you

Practice EBMPractice EBM so that it becomes secondso that it becomes second

naturenature to outo ou

Follow the guidelines and procedures whereFollow the guidelines and procedures where .. ..

and the patients from errorsand the patients from errors

Fo ow t e simp e ru es a out Open Disc osureFo ow t e simp e ru es a out Open Disc osureto keep you and your patients safeto keep you and your patients safe


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Maintain your own high standardsMaintain your own high standards

improvementimprovement

Be assertive if ou see mal ractice or errorsBe assertive if ou see mal ractice or errorsoccurring.occurring.

Have the courage to:Have the courage to: ask politely what is happeningask politely what is happening

or gently question the practiceor gently question the practice

Read the article cited below in notes!Read the article cited below in notes!

Learn from your mistakes and the mistakesLearn from your mistakes and the mistakesof othersof others


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Some examples of organisations tackling the issues of medical error andSome examples of organisations tackling the issues of medical error andhealthcare quality:healthcare quality:

Australian Resource Centre for Healthcare Innovations check out the eAustralian Resource Centre for Healthcare Innovations check out the e--librar :librar :http://www.archi.net.au/http://www.archi.net.au/

Clinical Excellence Commission. Browse through and see the quality issues that are being dealt with inClinical Excellence Commission. Browse through and see the quality issues that are being dealt with inNSW:NSW: http://www.cec.health.nsw.gov.au/http://www.cec.health.nsw.gov.au/

National Reporting and Learning ServiceNational Reporting and Learning Service. Similar site for the UK:. Similar site for the UK: http://www.nrls.npsa.nhs.uk/http://www.nrls.npsa.nhs.uk/

National Institute of Clinical Studies:National Institute of Clinical Studies: http://www.nicsl.com.au/http://www.nicsl.com.au/

healthcare in the USA):healthcare in the USA): http://www.ihi.org/ihihttp://www.ihi.org/ihi

Agency for Healthcare Research and Quality (USA)Agency for Healthcare Research and Quality (USA) scroll down for useful information documents:scroll down for useful information documents:http://www.ahrq.gov/qual/errorsix.htmhttp://www.ahrq.gov/qual/errorsix.htm

National Patient Safety Foundation (USA)National Patient Safety Foundation (USA) take a glance at the publications available here:take a glance at the publications available here:http://www.npsf.org/http://www.npsf.org/

Quality and Safety in Healthcare Journal (BMJ Publishing: accessible from campus):Quality and Safety in Healthcare Journal (BMJ Publishing: accessible from campus):htt : hc.bm ournals.comhtt : hc.bm ournals.com

SIN: Sufferers of Iatrogenic Neglect (fascinating)SIN: Sufferers of Iatrogenic Neglect (fascinating) -- http://www.sinhttp://www.sin--medicalmistakes.org/index.htmlmedicalmistakes.org/index.html

Medical errorMedical error


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re erencesre erences11 Wilson, R,Wilson, R, RuncimanRunciman, W,, W, GibberdGibberd, R, et al. (1995 ). The Quality in Australian, R, et al. (1995 ). The Quality in Australian

Health Care Study.Health Care Study. Med JMed J AustAust,, 163, 458163, 458--471.471.http://www.mja.com.au/public/issues/misc/wilson.pdfhttp://www.mja.com.au/public/issues/misc/wilson.pdf

And followAnd follow--up articles: Wilson 1999, MJA 170;411 and Wilson & Van Derup articles: Wilson 1999, MJA 170;411 and Wilson & Van DerWeyden 2005, MJA 182(6); 260Weyden 2005, MJA 182(6); 260--1.1.

22 Kohn, K, Corrigan, J, Donaldson M. (1999).Kohn, K, Corrigan, J, Donaldson M. (1999). To Err is Human: Building aTo Err is Human: Building a.. , ., .

33 RuncimanRunciman, W and Moller J. (2001)., W and Moller J. (2001). Iatrogenic Injury in Australia.Iatrogenic Injury in Australia. Canberra:Canberra:Commonwealth Department of Health and Aged Care.Commonwealth Department of Health and Aged Care.

44 LeapeLeape, L,, L, LawthersLawthers, A,, A, BrennenBrennen, T, Johnson, W. (1993). Preventing medical, T, Johnson, W. (1993). Preventing medicalinjury. QRB.injury. QRB. Quality Review BulletinQuality Review Bulletin, 19(5), 144, 19(5), 144--149.149.

55 Reason, J. (2000). Human error: models and management.Reason, J. (2000). Human error: models and management. BMJBMJ, 320, 768, 320, 768--..

55 LeapeLeape L. (1994). Error in Medicine.L. (1994). Error in Medicine.JAMAJAMA, 272, 1851, 272, 1851--1857.1857.

, , . ., , . . ..have we learned?have we learned?JAMAJAMA, 293, 2384, 293, 2384--2390.2390.


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Irvine. (2006).Irvine. (2006). MJA, 184,MJA, 184, 204.204.

Morrison. (2008).Morrison. (2008). Medical Education, 42,Medical Education, 42, 118.118.

PapadakisPapadakis et alet al. (2004). Unprofessional Behavior in Medical. (2004). Unprofessional Behavior in MedicalSchool is Associated with Subsequent Disciplinary Action by aSchool is Associated with Subsequent Disciplinary Action by a

a e e ca oar . ca em c e c ne, , .a e e ca oar . ca em c e c ne, , .

RabinowitzRabinowitz et al. (2004).et al. (2004). Med Teach 26Med Teach 26, 160., 160.

SwickSwick. (2000).. (2000).Academic Medicine 75Academic Medicine 75, 612., 612.

Tambl nTambl n et al. 2004 .et al. 2004 .Academic Medicine 79Academic Medicine 79 244244

Yates, J and James, DYates, J and James, D. (2010). Risk Factors at medical school. (2010). Risk Factors at medical schoolfor subsequent professional misconduct:for subsequent professional misconduct: multicentremulticentreretrospective case control. BMJ, 340, 2040.retrospective case control. BMJ, 340, 2040.


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and Auditand Audit

Dr Rachel ThompsonDr Rachel ThompsonQMP convenorQMP convenor

[email protected]@unsw.edu.au

Phase 2Phase 2-- Adult Health 1Adult Health 1

Remember that clinical audit isRemember that clinical audit is


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Remember that clinical audit isRemember that clinical audit is

AA c o n t i n u o u s c o n t i n u o u s process of reviewing healthcareprocess of reviewing healthcare

ualit ualit

against accepted / EBagainst accepted / EB standardsstandards

and implementingand implementing changeschanges to meet theto meet thestandard(s) as necessarystandard(s) as necessary

RepeatedRepeated to maintain highto maintain high standardsstandards

= A POSITIVE= A POSITIVE FEEDBACK LOOPFEEDBACK LOOP


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1.1. Identifying a problem or an issueIdentifying a problem or an issue

2.2. Set criteria / standards of careSet criteria / standards of care

3.3. Observe practice or collect dataObserve practice or collect data

..

5.5. Improvement of services / care to meet the standards ifImprovement of services / care to meet the standards ifindicatedindicated

What would you suggest to the practitionersWhat would you suggest to the practitioners should doshould doto improve their practice?to improve their practice?

Key differences between clinical


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researc auResearch What should be done Clinical Audit What is being done

New knowledge Tests given knowledge

Hypothesis Measures against set standards

Experiments Normal clinical management

Requires ethical approval Abides by and ethical framework

May involve random allocation and / or Neverinvolves thisplacebo groups

Large scale over a long time A relatively small short study

gorous me o o ogy eren me o o ogy rom researc

Results are generalisable Results are only relevant locally

S o u r c e : United Bristol Healthcare NHS Trust Clinical Audit Central Office. (2005). What is Clinical Audit? Retrieved online on08.06.06 from: http://www.ubht.nhs.uk/clinicalaudit/docs/HowTo/WhatisCA.pdf


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St Vincents Hospital Research Office Low Risk Projects Updated Feb 2010


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Same considerations as for clinical researchSame considerations as for clinical research

Mora imp icationsMora imp ications

Abbasi, K and Heath I. (2005). Editorial: Ethics review of research and audit.Abbasi, K and Heath I. (2005). Editorial: Ethics review of research and audit.BMJ,BMJ, 330, 431330, 431--432432

Wade, D. (2005). Ethics, audit, and research: all shades of grey.Wade, D. (2005). Ethics, audit, and research: all shades of grey. BMJ,BMJ, 330,330,468468--471471

Clinical Practice GuidelinesClinical Practice Guidelines


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-- arr ers o mp emen a onarr ers o mp emen a on

You are likely to see some real problems as toYou are likely to see some real problems as to

wh uidelines arenwh uidelines aren t full adhered to:t full adhered to:

What are the underlying causes?What are the underlying causes?


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BBurden of illness enough to warranturden of illness enough to warrant

implementing it?implementing it?

Are my patientsAre my patients BBeliefs compatible witheliefs compatible withimplementing it?implementing it?

Would the cost involved be a goodWould the cost involved be a good BBargain?argain?

overcome them?overcome them?

CostCost--effectiveness of implementingeffectiveness of implementinguidelinesuidelines


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....

..to my practice / hospital / community /..to my practice / hospital / community /

atient?atient?

How to apply them in practice depends onHow to apply them in practice depends on

Adapting them to your situation may reduceAdapting them to your situation may reducet eir va uet eir va ue

codecode


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AwarenessAwareness

FamiliarityFamiliarity AgreementAgreement

SelfSelf--efficacefficac

Outcome expectancyOutcome expectancy

Absence of external barriers to performAbsence of external barriers to performrecommendationsrecommendations

Cabana et. al (2000) Implementing practice guidelines for depression: Applying a new framework to an oldCabana et. al (2000) Implementing practice guidelines for depression: Applying a new framework to an oldproblem.problem. Gen Hosp PsychGen Hosp Psych, 24, 35, 24, 35--42.42.

Aw r nAw r n A h r n M l*A h r n M l*


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1.1. PrePre--awarenessawareness

2.2. AwarenessAwareness

3.3. A reementA reement

4.4. AdoptionAdoption

5.5. AdherenceAdherence

*Pathman et al. (1996). Awareness to adherence model of the steps to clinical guideline*Pathman et al. (1996). Awareness to adherence model of the steps to clinical guidelinecompliance.compliance. Med Care,34, 873Med Care,34, 873--89.89.

Tudiver et alTudiver et al ss


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DomainsDomains Physician characteristicsPhysician characteristics

Patient c aracteristicsPatient c aracteristics

Social factorsSocial factors

PracticePractice FactorsFactors

**Tudiver, F et al. (1998). Why donTudiver, F et al. (1998). Why don t family physicians follow clinical practice guidelines fort family physicians follow clinical practice guidelines forcancer screening?cancer screening? CMAJ,CMAJ, 159, 797159, 797--8.8.

..


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..

Physician characteristicsPhysician characteristics

Perceived effectiveness of guidelinesPerceived effectiveness of guidelines

CME levelCME level

Perceived probability of diseasePerceived probability of disease

..


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Patient characteristicsPatient characteristics

Knowledge and perception of patientsKnowledge and perception of patientswishes and social circumstances su ortwishes and social circumstances su ortsystemssystems

PatientsPatients attitudesattitudes

..


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Social factorsSocial factors

Interpersonal, persuasion, mass mediaInterpersonal, persuasion, mass media

Perceived endorsement and consistencyPerceived endorsement and consistencywith local practicewith local practice

..


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Practice Factors (GP)Practice Factors (GP)

TypeType solo / group, payment systemsolo / group, payment system

Perceived consultation timePerceived consultation time

Access to current infoAccess to current info

os s nvo veos s nvo ve

Evidence for CPGEvidence for CPG


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Comp ianceComp iance VariesVaries

Could be improvedCould be improved

Multifaceted approach linked to CMEMultifaceted approach linked to CME

Im rovements in racticeIm rovements in ractice efficiencefficienc

Examples:Examples:

feedback increased GP adherence to several guidelinesfeedback increased GP adherence to several guidelinesincluding BP screening*including BP screening*

assessmentassessment

**Bonevski et al. (1999). Randomised Controlled Trial of a Computer Strategy to Increase General Practitioner Preventive Care.Bonevski et al. (1999). Randomised Controlled Trial of a Computer Strategy to Increase General Practitioner Preventive Care.Preventive Med,Preventive Med, 29, 47829, 478--486.486.


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Essential part of clinical practiceEssential part of clinical practice

Adherence & keeping up can be a problemAdherence & keeping up can be a problem

Audit:Audit:

Essential part of clinical practiceEssential part of clinical practice

ProblematicProblematic -- involves intros ection and chan e ofinvolves intros ection and chan e ofpracticepractice

Ethical issuesEthical issues

Both are essential to &SBoth are essential to &S

GeneralGeneral adviceadvice for the minifor the mini--


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auauac groun researcac groun researc or n roor n ro

What is the CPG? Why is it important?What is the CPG? Why is it important?

o ce nee s o e suppor eo ce nee s o e suppor e

Reference itReference it

IntroductionIntroduction

n ca se ng s mpor ann ca se ng s mpor an

e oe o

Selection of casesSelection of cases random (how?) vs. consecutive casesrandom (how?) vs. consecutive cases

aper vs. serva onaper vs. serva on

General Advice for theGeneral Advice for the


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minimini--au it 2au it 2e oe o concon

Mention if you worked with a colleague on theMention if you worked with a colleague on the proformaproforma

report with your own writing in all sections (Results willreport with your own writing in all sections (Results willbe similar but should be written separately toobe similar but should be written separately too))

ReferencingReferencing

Reference the CPG and any evidence you use!Reference the CPG and any evidence you use!

APA. IfAPA. If more than one or 2 references vs. footnotes /more than one or 2 references vs. footnotes /endnotes andendnotes and bibliographybibliography

FormattingFormatting

PPT slidesPPT slides use our common sense!use our common sense!

--


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Put all results in this sectionPut all results in this section

Illustrate and demonstrate yourIllustrate and demonstrate your findingsfindings

DemographicsDemographics

AgeAge--range, mean / medianrange, mean / median

Plot, agePlot, age--groupsgroups

Re dataRe data--handlinghandling

Use tables better: summarise, use totals, % if big enoughUse tables better: summarise, use totals, % if big enoughnumbers, shading rather than colournumbers, shading rather than colour etcetc

ummary a e =ummary a e = summary see examp essummary see examp es

Plot results to see if distribution shows something then includePlot results to see if distribution shows something then includera hs if showsra hs if shows somethinsomethin

Show totals (e.g. n=10)Show totals (e.g. n=10)

GraphsGraphs gender /agegender /age


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examp eexamp e

2

2.5

umber

0.5

1

.

tien

tN

Female

50-59 60-69 70-79 80-89

P

Gra hsGra hs risk summar exam lerisk summar exam le


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Alcohol

Smoking

ctor

Established Disease

High BMI

RiskF

Biological Risk

Lower SES

0 2 4 6 8 10 12

Patient Numbers

Male Female Total


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Risk factor Yes No Not recorded N/A Total

Indigenous

Smoking (ex-smokers)

BMI >25

Physical Inactivity

Lower SES

Psychological factors

Excess alcoholconsumption

Biological risk

Established disease

Total with risk

codecode


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Risk

category

No. of

patients

No. with

appropriate BP

No. with

lifestyle

No. with

Absolute CVR

No. with criteria

for CVR

measurement(%)

counselling(%)

assessment(%)

satisfied(%)

Average

Increased

High

codecode


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What did findings show?What did findings show?

W at cou ave cause t is?W at cou ave cause t is?

What could ou su est to im rove thisWhat could ou su est to im rove thispractice?practice?

Reflection generally good but lack personalReflection generally good but lack personal

element in some reportselement in some reports


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Problems:Problems:

ac o resourcesac o resources

lack of ex ertise or advice in ro ect desi nlack of ex ertise or advice in ro ect desi nand analysisand analysis

membersmembers

lack of an overall plan for auditlack of an overall plan for audit

or anisationalor anisational im edimentsim ediments

Johnston et al. (2000). Reviewing audit: barriers and facilitating factors for effective clinical audit

Qual Saf Health Care, 9, 23-36

Key facilitating factors to auditKey facilitating factors to auditwere a so en e :were a so en e :


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modern medical records systemsmodern medical records systems

e ective traininge ective training

dedicated staffdedicated staff

protected timeprotected time

structured programmesstructured programmes

providersproviders

Useful Feedback fromUseful Feedback from


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prev ous au sprev ous au s Background literature: qualitative studies, RCTs, auditsBackground literature: qualitative studies, RCTs, audits

. .. .

CanCan tt do inferential stats asdo inferential stats as such as is not a truesuch as is not a truesam le and ou are not testin a h othesis butsam le and ou are not testin a h othesis but::

Can look at demo ra hics and descri tive statistics e. .Can look at demo ra hics and descri tive statistics e. .number out of total or % completed managementnumber out of total or % completed management etcetc))

Can draw quite strong conclusions and makeCan draw quite strong conclusions and makerecommendationsrecommendations

Small size of audit: can still be useful.Small size of audit: can still be useful. remember that youremember that youcancan audit one case!audit one case!


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Set ex licit ESet ex licit E--B criteria and standardsB criteria and standards Use objectiveUse objective measurements of practicemeasurements of practice

necessary to improve the investigated outcomesnecessary to improve the investigated outcomes

A hi hA hi h standard of documentationstandard of documentation

AdaptedAdapted fromfrom:: Shaw, C.Shaw, C. Audit PhilosophyAudit Philosophy in:in: FrostickFrostick, S., Radford, P. and Wallace, W., S., Radford, P. and Wallace, W.(1993). Medical Audit. Rationale and practicalities. Cambridge University Press: Cambridge.(1993). Medical Audit. Rationale and practicalities. Cambridge University Press: Cambridge.P. 20P. 20--1.1.

K in wi h i linK in wi h i lin


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Guidelines change quite frequently soGuidelines change quite frequently so

ractitioners ust et used to them and thenractitioners ust et used to them and thenthey are updatedthey are updated

Try to read guideline summaries and recentTry to read guideline summaries and recentjourna s w en you are t ere i possi ejourna s w en you are t ere i possi e


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PresentPresent to clinicalto clinical tutor with PPT slides intutor with PPT slides in

week 6week 6 Submit viaSubmit via eMedeMed at end of weekat end of week 6 for your6 for your

Discuss with clinical tutor ifDiscuss with clinical tutor if difficulties withdifficulties withthe audit /the audit / submissionsubmission etcetc

Email me if not able to resolve:Email me if not able to resolve:[email protected]@unsw.edu.au

Documents

Medical Error and Professionalism