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LEARNING FROM INCIDENTS

LEARNING FROM INCIDENTS. Dr Bill Kirkup. CONTENT. Straightforward pathway Incidents and recognition Reporting and analysis Implementing improvement Major incidents Critical points and principles. Incident. Recognition. Analysis and Reporting. Learning. Errors, slips, lapses

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LEARNING FROM INCIDENTS

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  1. LEARNING FROM INCIDENTS Dr Bill Kirkup

  2. CONTENT • Straightforward pathway • Incidents and recognition • Reportingand analysis • Implementing improvement • Major incidents • Critical points and principles

  3. Incident Recognition Analysis and Reporting Learning Errors, slips, lapses Price for complex skills Systems factors predominate But also competence/conduct Often depends on admission Socialisation and role models Institutional response Denial (including self) What and why (root cause) Identify prevention Improving knowledge of risk Spotting trends System design improvement Implement local change Communicating findings Enable wider change FROM INCIDENT TO LEARNING

  4. INCIDENTS AND RECOGNITION • Ingrowing toenail 38 weeks pregnancy • Sepsis; OP appointment 6 months • SHO offered removal with local anaesthetic • Plain lignocaine required for ring block • Checked ampoule, drew up lignocaine • Rechecked ampoule • With adrenaline...

  5. POTENTIAL LESSONS • Wrong setting: antenatal clinic • Other staff unfamiliar with procedure • Poor labelling, especially glass ampoules • Anticipation affects perception Seeing what you you expect

  6. SYSTEMS FAILURES • Ladbroke Grove rail crash 1999 • Head on collision, high combined speed • ‘Signal passed at danger’ (SPAD) • 8 previous SPADs in 6 years at location • Site and design of signal • Ineffective points interlocking • Inadequate driver training • Lack of route experience

  7. LONGSTANDING FEATURE Those entering hospital… …were exposed to more chances of death than was the English soldier on the field of Waterloo JY Simpson

  8. Donald Robertson 1785-1848 His death was much regretted which was caused by the stupidity of Laurence Tulloch in Clothister (Sullom) who sold him nitre instead of Epsom salts by which he was killed in the space of 5 hours after taking a dose of it. Gravestone inscription, Shetland Isles

  9. WORLDWIDE RESEARCH • 10% of hospital admissions result in an adverse event • 8% contribute to fatal outcome • 6% cause serious impairment • 50% of incidents are avoidable

  10. CONSEQUENCES • 16 patients suffer injury or harm each day • 11 avoidable deaths occur each day • Patient safety incidents cost £3billion each year

  11. HOW RISKY IS HEALTHCARE? • Less than one death per 100,000 episodes • Nuclear power • European railways • Scheduled airlines • One death per 1,000 - 100,000 episodes • Driving in UK • Chemical manufacturing • More than one death per 1,000 episodes • Bungee jumping • Mountain climbing • Healthcare

  12. INCIDENT REPORTING NPSA Figures for England

  13. DEGREE OF HARM REPORTED

  14. REPORTED AGAINST EXPECTED Expected from cumulative research Observed, NPSA 2010 (Acute Sector)

  15. CRITICAL POINT 1: BLAME • 90% not individual factors • Pressure for scapegoat • victims, public, media • Systems seem nebulous • ‘who is accountable?’ • Blame is ‘emotionally more satisfying’ (Reason) • Counter to developing open reporting and learning culture • ‘Encouraging the others’ is ineffective

  16. LEARNING: IMPROVING SYSTEMS

  17. Wayne Jowett • 18 years old, an apprentice mechanic • In remission from leukaemia • Anti-cancer drug injected into spine instead of vein • Died one month later • 48 failures of procedure traced

  18. A SYSTEM SOLUTION? • Universal use of Luer lock connections • Wide range of misconnections possible • Design and introduce non-Luer system • Programme commenced 2002 • Design, correction, piloting until 2009 • Further problems evident • 31/1/2011 PSA: April 2012

  19. November 2000 Death of 3-year-old girl, Newham May 2001 Notice on machine safety issued October 2001 Compliance reports from CEs July 2002 186/5657 non-compliant, 139 in use November 2002 All machines reported compliant 2003 Survey: 25 Trusts non-compliant January 2005 Final notice issued IMPLEMENTING SYSTEM SOLUTIONS

  20. ORAL METHOTREXATE Compliance with Alert issued July 2004 Source: CMO Annual Report, 2004

  21. ORAL METHOTREXATE ALERT Compliance at 300 days by SHA Source: CMO Annual Report, 2004

  22. NPSA 2006/07 • 18% NHS organisations still not compliant after two years • 14 incidents led to 2004 alert • Since alert, 151 further incidents • Progress since?

  23. THE ORANGE WIRE TEST The Lancet 2004; 365: 1567-1568

  24. CRITICAL POINT 2: LEARNING • “It could never happen here” • “The solution won’t work here” • “We have more pressing priorities” • The Streeb-Greebling Effect: “Have you learned from your mistakes, Sir Arthur?” “Yes I have, and I could repeat them all perfectly”

  25. MAJOR INCIDENTS

  26. MRS MAVIS SKEET • Age 73, Wakefield, oesophageal cancer 1999 • Good response from radiotherapy May 1999 • Further difficulty swallowing September 1999 • Endoscopy October 1999 showed recurrence • Surgery planned Leeds General Infirmary • 6/12/99: cancelled, anaesthetist unwell • 20/12/99: cancelled, no ICU bed • 27-29/12/99: no ICU bed available • 10/1/00: cancelled, no ICU bed • 11/1/00: endoscopy – trachea fixed • Repeat radiotherapy (palliative)

  27. “Dear Mr Blair” “I write to you today to ask why I must suffer the agony of watching my mother slowly die” (Daughter) • “Cancer inoperable after flu delay” (BBC) • “Cancer sufferer doomed by flu delay” (Guardian) • “The NHS is not working…” (Observer) • “National outrage…” (Mail) • “NHS in crisis” (Mirror) • “… she had a right to live but she won’t” (S Mirror) • “In Britain’s Health Service, sick itself, cancer care is dismal” (New York Times) “The Health Secretary, Alan Milburn, has ordered an inquiry into a hospital's treatment of a cancer patient after surgery cancelled four times has left the cancer inoperable” (Independent)

  28. REPORT ON TREATMENT AND CAREof Mrs Mavis Skeet by Leeds Teaching Hospitals NHS Trust February 2000 • Initial expectation: ‘name, shame and blame’ • Clear evidence from occupancy patterns: • all 40 ICU beds across Leeds consistently full • patients being ventilated in recovery areas • emergency transfers declined several times • Review confirmed decisions and their basis • “A serious deficiency in quality of NHS care” • Root cause: increased specialist transfers; capacity • “A further increase in critical care facilities… a priority to minimise the risk of recurrence”

  29. SUBSEQUENT EVENTS • Immediate additional 450 ICU beds funded • Regional bed bureaus to co-ordinate capacity • But also: • ‘Breakfast with Frost’ pledge on NHS funding • reversal of previous hospital bed policy “When it comes to writing the first draft of political history, the name of Mavis Skeet will probably not even merit a footnote” (Guardian, 2002) “It is hard now to look back and realise just how inevitable such crises appeared” (Blair, T: A Journey 2010 p261) Mrs Skeet died June 2000

  30. “AN APPALLING INCIDENT”

  31. MIDDLESBROUGH GENERAL HOSPITAL • Patient A, aged 60+, admitted to MGH 2002 • cognitive impairment including memory loss • no ataxia, no myoclonus, stable over 8 months • probable cerebral vasculitis or dementia • brain biopsy July 2002 to exclude vasculitis • Histology: no vasculitis seen, further tests • Later some vacuoles seen, sent to Edinburgh • 8 August 2002: CJD identified in sample • CJD Incidents Panel contacted • 34 patients potentially at risk • panel meeting due 17 October 2002 • instruments quarantined

  32. ‘THE GUARDIAN’ STEPS IN • CJD Incidents Panel Meeting 17 October: • brain biopsy to confirm clinical picture of CJD? • critical of instrument decontamination procedures • considered 29 patients at risk, to be contacted • draft letter awaiting signature 11 days later • Leaked information with The Guardian • Story went live 29 October 2002 DH Media team statement: “The guidance issued to the NHS in August 1999 is crystal clear. Instruments used on any suspected cases of CJD must be quarantined immediately after use pending confirmation of the diagnosis. All NHS Trusts should adhere to this guidance to prevent avoidable and unnecessary exposure to these diseases. In this case it appears that the Trust concerned failed to do so and as a result we need to check what patients have been put at risk. Described as an appalling incident.”

  33. PRESS COVERAGE PREDICTABLE • Extensive national media coverage • “Hospital blunder…fatal brain disease” (All) • “Appalling incident…failures” (Most) • “The Department of Health last night confirmed ‘an appalling incident’ had taken place…in which the hospital had failed to prevent avoidable exposure…” (Guardian) • “Row over hospital blunder” (Most) This is how 29 people who had potentially been exposed to CJD found out. So did 150+ who had neurosurgery at that time but who had not been exposed to transmission.

  34. REPORT OF INCIDENT REVIEW • Did the Trust follow the right quarantine procedure? • Is manual instrument decontamination acceptable? • Should there be a tracing system for surgical instruments? • Was the CJD Incidents Panel advice helpful and timely? • Was DH media line well-informed? • Was the Trust’s handling right?

  35. RECOMMENDATIONS AND OUTCOME • Quarantine (non-focal) brain biopsy instruments • Reform operation of CJD Incidents Panel • Clarify guidance on manual decontamination • Make instrument tracking mandatory • Improve DH Comms Department’s local liaison • Commend NHS staff

  36. INDIVIDUALS AND SYSTEMS • 1970: O&G training; Canada 1977 • 1979: lost privileges BC, postop death • 1981: investigation Ontario, maternal death • 1984: appointed consultant Northallerton • 1985: erased Canadian medical register • 1989: ‘woeful and inadequate’ investigation • 1991: Richmond public toilet incident • 1993: ‘overly positive’ investigation • 1995: on-call problems; left Trust • 1996: assaulted porter, Leicester • 1999: patient complaints emerged • 2000: GMC erased UK register

  37. SYSTEMS FAILURES • Lack of pattern recognition • Poor communication • Misuse of references • Reliance on colleagues • Constraints of consultant terms

  38. CRITICAL POINT 3: PATTERNS • Pattern recognition usually good • If anything, usually too prone to find • But requires information to examine • Incidents considered in isolation • Incidents considered without context • Information may not be shared • across borders • between systems • between organisations

  39. CONCLUSION: SOME PRINCIPLES? “These are my principles. If you don’t like them, I have others.”

  40. CONTEXT “The UK’s problems in providing safe care are shared by most developed countries. But the UK led the world in confronting the issues….” • extensive clinical governance systems • national reporting and learning • unprecedented rates of reporting • 72 current patient safety alerts Kennedy: Learning from Bristol: Are we? As a result, the NHS now has: • but still clear problems in learning

  41. CRITICAL POINT 1: BLAME • Powerful disincentive (whatever source) • Suppresses most reporting • But encourages trivial reports • Blanket disciplinary edicts unhelpful • RCAs not part of disciplinary process • ‘Encouraging the others’ remains ineffective

  42. CRITICAL POINT 2: LEARNING • Most root causes are reproducible • ‘It could happen here’ • Solutions can be invented elsewhere • Is patient safety a priority? • Engagement, commitment, leadership • Or risk repeating our mistakes perfectly

  43. CRITICAL POINT 3: PATTERNS • Look at previous history • Share information (eg references) • Incidents don’t happen in isolation • Monitoring and audit • Statistical techniques can help

  44. FINAL COMMENT Events beat strategy every time

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