Patient Safety What should we be trying to communicate?

1. Patient SafetyWhat 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

2. Overview • Understanding patient safety • What have we learned so far? • Teams create safety • So what should we try to communicate in education and training?

3. Imperial Academic Health Sciences Centre

4. 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

5. 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

6. 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)

7. Patient Safety in the UK

8. UK Department of Health, 2000

10. Epidemiologyof harm

11. The unreliability of healthcare Undre et al, 2006

12. Understanding why things go wrong

13. The safety paradox • Healthcare staff are: • Highly trained & motivated • Committed to their patients • Use sophisticated technology • Errors are common and patients are frequently harmed

14. 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

15. Contributory factors: 7 levels of safety • Patient • Task • Individual staff • Team • Working conditions • Organisational • Government and regulatory Vincent, Adams, Stanhope 1998

16. Teams create safety

17. 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

19. 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 The Impact of Daily Goals Pronovost, 2003

20. II Patient handover Multiple specialists Complex tasks Complex interfaces Time pressure Need for accuracy Catchpole et al, 2007

21. Process Organisation 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 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 Pit Stop Handover Catchpole et al, 2007

22. Performance improvements with new handover protocol Number of Errors Information Omissions Duration (mins) Observation of 23 pre- and 27 post- handovers, balanced for operative risk

23. III Care bundles & organisational change

24. 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 Decreasing catheter related bloodstream infections

25. 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

26. So what should we try to communicate?

27. 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)

28. The essentials of patient safety • The human tragedies • Scale of error and harm • The safety paradox • Reflecting on one’s 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

29. 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)

30. 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)

32. Clinical Safety Research Unitwww.csru.org.ukCentre for Patient Safety & Service Qualitywww.cpssq.org Further Information