Patient Safety

What should we be trying to communicate?

Making Tomorrows Doctors Safer
January 2011
Charles Vincent
Professor of Clinical Safety Research
Department of Surgical Oncology & Technology
Imperial College London
www.cpssq.org

Overview

Understanding patient safety

What have we learned so far?
Teams create safety
So what should we try to communicate in
education and training?

Imperial Academic Health Sciences Centre

Defining patient safety

`The avoidance, prevention and amelioration of

adverse outcomes or injuries stemming from the
process of healthcare
Negative or positive
Reactive or proactive
An Aspiration & Ambition
One of a number of objectives
The heart of quality

Consequences of serious adverse events

for patients & families

Death of neonates, children, adults

Loss of womb in young women
Untreated cancer, mastectomy
Blindness
Disability and handicap, children and adults
Chronic pain, scarring, incontinence
Profound effects on all aspects of their lives

Vincent, Young & Phillips, 1994

Impact of mistakes

`I was really shaken. My whole feeling of self worth

and ability was basically profoundly shaken
`I was appalled and devastated that I had done this to
somebody
`My great fear was that I had missed something, then
there was a sense of panic
`It was hard to concentrate on anything else because I
was so worried (Christensen, 1992)

Patient Safety in the UK

UK Department of Health, 2000

Epidemiology of harm
Study

Date of
admissions

Number of hospital
admissions

Adverse event rate

(% admissions)

California Insurance
Study

1974

20864

4.65 *

Harvard Medical
Practice Study

1984

30195

3.7

Utah-Colorado

1992

14052

2.9

Australian

1992

14179

16.6

United Kingdom

1999

1014

10.8

Denmark

1998

1097

9.0

New Zealand

1998

6579

11.2

France **

2002

778

14.5

Canada

2000

3745

7.5

The unreliability of healthcare

Undre et al, 2006

Understanding why things go wrong

The safety paradox

Healthcare staff are:

Highly trained & motivated

Committed to their patients

Use sophisticated technology

Errors are common and patients are frequently

harmed

Understanding why things go wrong

Chain of events
Complexity and contributory factors
The importance of cumulative minor errors
and deviations
Tackling safety on many levels

Contributory factors: 7 levels of safety

Patient
Task
Individual staff
Team
Working conditions
Organisational
Government and regulatory
Vincent, Adams, Stanhope 1998

Teams create safety

I Reliability of ward care

(1) How well do you understand the goals of care

for this patient today?
(2) How well do you understand what work needs
to be accomplished to get this patient to the next
level of care?
Less than 10% of nurses or doctors could answer
these questions

Pronovost et al, 2003

The Impact of Daily Goals

Structured and
organised care for each
patient
Reliability reducing
the gap between what
should be happening
and what is actually
happening
Reduced length of stay
from 2.5 to 1.3 days

Pronovost, 2003

II Patient handover

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Multiple specialists
Complex tasks
Complex interfaces
Time pressure
Need for accuracy

Catchpole et al, 2007

Process Organisation
Pit Stop

Task sequence
A rhythm and order to events

Task allocation
Team members have defined tasks

Leadership

Who is in charge
Discipline and composure
Explicit communication strategies to
ensure calm and organised atmosphere

Handover
Stages in process clearly defined

Ventilation: Anaesthetists
Monitoring: ODA
Drains: Nurses

Anaesthetist has overall responsibility

Defined moment for transfer to intensivist
Comms limited during equipment phase
Order for briefing (Anes; Surg; Discuss;Plan)
No interruptions

Catchpole et al, 2007

Performance improvements with new

handover protocol
Observation of 23 pre- and 27 post- handovers, balanced for operative risk

Number of Errors

Information Omissions

Duration (mins)

III Care bundles & organisational change

Decreasing catheter related bloodstream

infections

Hand washing
Full barrier precautions
during the insertion of
central venous catheters
Cleaning the skin with
chlorhexidine
Avoiding the femoral site
if possible
Removing unnecessary
catheters

Median rate of infection

per 1000 catheter days
decreased from 2.7 at
baseline to 0 at 3 months
Mean rate at baseline
decreased from 7.7 to 1.4
at 16-18 months follow up

Care bundles & organisational change

A focus on systems
Local ownership and engagement
Encouraging local adaptation of the intervention
Creating a collaborative culture
Time and resources

Pronovost et al, 2008

So what should we try to communicate?

Becoming aware

Communication in Emergency Care

Tracking the process `I just could not believe
we were doing all this
Observing the handover `Staggering, jaw
dropping
Putting on my `second hat (Krishna Moorthy)

The essentials of patient safety

The human tragedies

Scale of error and harm
The safety paradox
Reflecting on ones own environment
The informal nature of many healthcare processes
The many levels of influence and intervention
The potential for simple changes
That they can make a difference

Safety in clinical practice I

I do not undertake any procedure unless I am sure I am

competent in performing it or have adequate supervision.
Senior clinicians say they want juniors to err on the side of
safety yet many younger clinicians fear seeming weak. I
make a point to reminding myself day after day that I want
to be safe first and brave afterwards.
Spending longer with patients explaining and discussing
the risks and benefits of treatment
Being obsessive about hand washing. I am now very aware
of why we are asked to do this and so less irritated about
the time it takes
Having enough humility to recognize when you are
stepping beyond your depth and willingness to ask for help
(Jacklin, Undre, Olsen)

Safety in clinical practice II

Being more vigilant in terms of errors that occur in day to

day practice which I may have missed in the past.
Being willing to address loose ends rather than say this is
not part of my problem.
Involving the patient in their care. For example always
asking the patient which side they thought they were
having the operation.
Being more explicit about my instructions, discussing
everything I think or intend to do to with the patient
At handover always summarising the situation, outlining
the plan and being absolutely clear about what to monitor
and at what point I want to be called
(Jacklin, Undre, Olsen)

Further Information

Clinical Safety Research Unit

www.csru.org.uk
Centre for Patient Safety & Service Quality
www.cpssq.org