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The Future of Patient SafetySeeing safety through the patient’s eyes
Rene Amalberti & Charles Vincent
Department of Experimental Psychology, Nuffield Department of Surgical Sciences
University of Oxford
Overview
Our current view of patient safety Broadening our view of harm: through the patient’s
eyes Starting from reality: 5 levels of care Safety along the patient journey Models of safety across settings Implications and directions
– Models of event analysis– The nature of safety interventions– The challenge of home care
The nature of harm
Incidents, accidents Adverse events Near misses, close calls etc. Relatively circumscribed events
– Hospital based (for the most part)– They have a history, but a short one– Observed by healthcare professionals
Incidents within a patient journey(Healthcare professionals’ view)
Good care + incidents
Shekelle et al, 2013
Targeted at events
Aim is to optimise reliability of basic procedures
Patient safety outside the hospital?
Little developed Little traction?
– Lack of interest?– Lack of infrastructure?– No incentives?– Wrong language and concepts?
I Broadening our view of harmThrough the patient’s eyes
Patient harm happens in every healthcare setting: at home in convalescence, in an operating room under anaesthesia, at the lab getting
blood drawn, in the hospital corridor lying alone on a stretcher ……
Harm may result from wrong or missed diagnosis, scheduling delay, poor hygiene, mistaken identity, unnoticed symptoms, hostile behaviour, device malfunction, confusing instructions, insensitive language and hazardous
surroundings.
The trajectory of harm begins with the unexpected experience of harm arising from or associated with the provision of care, including acts of both commission and omission……... The patient may experience harm during the episode of care when the failure occurred, or later, after some time has
passed. Harm as it is first endured may evolve, transform and spread (Canfield, 2013)
Harm through the patient’s eyes
Harm is conceived very broadly encompassing both serious disruption of treatment and distressing events.
Harm includes serious failures to provide appropriate treatment as well as harm that occurs over and above the treatment provided.
Harm is seen not in terms of incidents but as a trajectory within a person’s life.
A broader view of harm
Treatment specific harm Harm due to over treatment General harm from healthcare Harm due to failure to provide appropriate treatment Harm due to failed or inadequate diagnosis Psychological harm and feeling unsafe Harm due to neglect and dehumanisation
Explore dimensions of harm in each setting
Hospital acquired syndromes in care of the elderly– Dehydration – Malnutrition– Delirium – Depression – Pressure sores – Incontinence
II Starting from realityFive levels of care
Are our clinical systems and processes reliable?
• Measuring and testing reliability: the WISER study –– Clinical information availability at the point of decision
making– Prescribing for hospital inpatients– Equipment in theatres– Equipment for inserting IV lines– Handover between wards
• Past medical history• Referral letter/other specialty letter• Discharge summary • Current medication• Radiology/imaging results• Diagnostic test results• Procedure notes/anaesthetic record • Electrocardiogram (ECG) report• Blood results
I’m looking for...
15% of patients with missing information
across 3 hospitals
Equipment availability in operating theatres
19% of operations with one or more equipment
problem
Quality ambition- Optimal care(almost never reached)
5 Care where harm undermines any benefits obtained
Threat to health
OPTIMAL BENEFIT
INCREASED RISK OF HARM
1 The care envisaged by standards
3 Unreliable care/ poor qualityThe patient escapes harm
2 Compliance with standards- ordinary care with imperfections
4 Poor care with probable minor harm but overall benefits
Area of Safety
Area of Quality
5 levels of care
‘The illegal normal’
Quality ambition- Optimal care(almost never reached)
5. Care where harm undermines any benefits obtained
Threat to health
OPTIMAL BENEFIT
INCREASED RISK OF HARM
1The care envisaged by standards
3. Unreliable care/ poor qualityThe patient escapes harm
2. compliance with standards- ordinary care with imperfections
4. Poor care with probable minor harm but overall benefits
Interventions to optimise reliability
Interventions to
reduce harm
The same thing?
III Safety along the patient journeyThrough the patient’s eyes
IV Managing safety in different contexts
No system
beyond this point
10-2 10-3 10-4 10-5 10-6
Civil Aviation
Nuclear Industry
Railways
Chartered Flight
Drilling Industry
Chemical Industry (total)
Fatal risk
Anesthesiology ASA1
Innovative medicine (grafts, oncology …) ICU Trauma centers
Very unsafe Ultra safe
Professional fishing
Three Contrasted Safety models
Unsafe Safe
Himalayamountaineering
Combat A/C, war time
Medical risk (total)
Scheduled surgery Chronic care
Radiotherapy, BiologyBlood transfusion
Finance Fire FightingFood Industry
Processing Industry
2014
Embracing risk: ultra-resilient:
Taking risks is the essence of the profession
Cult of champions and heroes Power to the experts – ‘give me
the best tools to survive’ Success analysis more
important than accident analysis
Training. Experts talk to juniors, acquisition of expertise, understanding own limitations
Managing risk: high reliability model
Risk in not sought out but is inherent in the profession
Group intelligence and adaptation
Mutual protection team members. Suspicion of simple explanations
Training and safety focused on adaptability and flexibility of procedures
Avoiding risk: ultra safe
Risk is excluded as far as possible
Procedures & supervisory systems
Priority given to prevention Strong regulatory control Training focused on rigorous
procedures and management of workload
Models of safety within healthcare
Embracing risk - Ultra resilient– Treatment of cancers with poor prognosis, military
medicine, major trauma surgery Managing risk – HRO model
– Elective surgery, obstetrics Ultra-safe
– Laboratory medicine, blood products, radiotherapy
A model of safety for care in the home?
?
?
?
Rethinking patient safety
Redefining patient safety
Patient safety is the art of controlling risks of time to minimize harm (isolated or cumulative) in relation to benefits
The reduction of all incidents and minor harm is a secondary, though still desirable, objective.
Analysis should focus on understanding the ‘EVENT’ JOURNEY’: the sum of events positive and negative that make at end the care successful or tragic
Neither total compliance, nor zero harm
With this definition, patient safety is: – Not a ‘zero default’ approach with total elimination of
any harm or incidents. – Not primarily a ‘process-driven’ approach aimed at
total compliance with procedures, whatever the value of these procedures
The nature of safety interventions
Interventions need to be targeted at the real world not at the ideal world of regulations and standards
Optimal interventions will differ according to context There is a limit to optimising reliability Focus on risk control and mitigation as well as on error
prevention and causation Stronger focus on organisational interventions and
building foundations of safety