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Patient safety, clinical governance and risk management. Stuart Emslie WHO consultant to KKM. Stuart Emslie. Former academic, Strathclyde University, Scotland, specialising in healthcare risk management
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Patient safety, clinical governance and risk management Stuart Emslie WHO consultant to KKM
Stuart Emslie • Former academic, Strathclyde University, Scotland, specialising in healthcare risk management • Formerly Head of Controls Assurance for the National Health Service in England, Dept. of Health • Currently independent healthcare consultant specialising in healthcare governance, risk management and patient safety • World Health Organisation (WHO) consultant on clinical governance, risk management & patient safety to Malaysian Ministry of Health • Visiting Fellow in healthcare governance and risk management at Loughborough University, England – developed and leads part-time MSc degree in healthcare governance • Visiting Lecturer, clinical governance, Oxford University Medical School, England • Visiting Lecturer, risk management & clinical governance, Flinders University School of Medicine, Australia (China & Singapore) • Advisor on clinical governance to Health Service Executive, Ireland
Objectives • Understand ‘clinical governance’ (including patient safety and risk management) • Explore the Irish framework for ‘integrated quality, safety and risk management’ as a means of achieving ‘excellence in clinical governance’ • Determine whether the Irish framework might be worthy of adoption by KKM for public hospitals in Malaysia and what modifications to the framework would be required.
“Medicine used to be simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous.” Sir Cyril Chantler Former Dean Guy’s & St Thomas’s Medical & Dental School London
Technology Development and Risk in Healthcare Technology Development Development Risk Gap Training Time c1980 c2001 c1950 Source: Chris Quinn, Newcastle Hospitals NHS Trust, England
‘UK: blunders by doctors kill 40,000 a year’Sunday Times, 19 Dec 1999 “Medical error is the third most frequent cause of death in Britain after cancer and heart disease…….kills four times more people than die from all other types of accidents.” NB – USA approx. 98,000/year; Australia approx. 10,000/year
Hospital condemned over deaths after 'appalling' failures in careHealth secretary apologises over damning report on Mid Staffordshire NHS trust “Between 400 and 1,200 more people died than would have been expected at Mid Staffordshire NHS foundation trust over three years…. Although it is not clear how many of these deaths could have been avoided, the Healthcare Commission said patients undoubtedly suffered as a result of lapses in the standard of care.” 17 March 2009
Mirror.co.uk NEWS
Examples…… • Aintree Hospital – a tube that was helping the patient breathe dislodged, causing a fatal heart attack and in separate incident a chest drain being inserted to relieve pressure on the lungs pierced the heart with “horrific” consequences • Death of a patient at York given the wrong medication • A missed diagnosis of meningitis led to a child’s death at East Kent Trust • At the Royal Hampshire County Hospital 23 patients died of C.diff • Five babies on the neo-natal unit contracted MRSA at Winchester and Eastleigh • A swab was left inside a patient’s abdomen after a caesarean last June at Queen Mary’s Sidcup NHS Trust • At East Cheshire NHS Trust a patient had the wrong part of their body operated on • etc.
Average 8.9% 3.4%
Doctors v. Gun Owners Number of physicians in the US = 700,000 Accidental deaths ‘caused by physicians’/year = 98,000 Accidental deaths/physician per year = 0.14 Number of gun owners in US = 80,000,000 Number of accidental gun deaths/year = 1500 Accidental deaths/gun owner =.0000188 ?Conclusion - Doctors are approximately 7500 times more dangerous than gun owners!
“Why do doctors kill more people than airline pilots? Airline pilots are required to have time off to sleep, do everything in duplicate and follow protocols.” British Medical Journal Vol 1 317 1998
ROOT CAUSE ANALYSIS Improving the safety and quality of care by investigating and analysing incidents and issues to determine what went wrong, why, and the actions necessary to prevent recurrence
“Improvement strategies that punish individual clinicians are misguided and do not work. Fixing dysfunctional systems on the other hand is the work that needs to be done” Saul Weingart, Harvard Executive, Session on Medical Error and Patient Safety
Bristol Royal Infirmary In the period from 1991 to 1995 between 30 and 35 more children under 1 died after open-heart surgery in the Bristol unit than might be expected had the unit been typical of other PCS units in England at the time.
Clinical Governance “A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.” “… the framework through which organisations influence the informal psychological and social functioning of their staff.”
"Clinical governance is the vital ingredient which will enable us to achieve a Health Service in which the quality of health care is paramount. The best definition that I have seen of clinical governance is simply that it means "corporate accountability for clinical performance". Clinical governance will not replace professional self regulation and individual clinical judgement, concepts that lie at the heart of health care in this country. But it will add an extra dimension that will provide the public with guarantees about standards of clinical care." Dr Sam Galbraith MPMinister for Health (Scotland)June 1998
and clinical decision-making based on up-to-date evidence of effectiveness Including staff continuing professional development (CPD) Source: Based on National Audit Office
Personal Work Read the Framework document, have a restful sleep and good breakfast, and come prepared tomorrow morning to do a self-assessment against the Framework document as a basis for moving forward over the next 2 days.
