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Patient Safety and Healthcare Improvement at a Glance Edited by Sukhmeet S. Panesar Andrew Carson-Stevens Sarah A. Salvilla Aziz Sheikh

Patient Safety and Healthcare Improvement at a Glance

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Patient Safety and Healthcare Improvement at a Glance Edited by

Sukhmeet S. Panesar BSc (Hons.), MBBS, AICSM, MPH, MD Honorary Fellow Centre for Population Health Sciences The University of Edinburgh Edinburgh, UK

Andrew Carson-Stevens BSc (Hons.), MB BCh, MPhil Clinical Lecturer in Healthcare Improvement Cochrane Institute of Primary Care and Public Health Cardiff University School of Medicine Cardiff, UK

Sarah A. Salvilla BSc (Hons.), MBBS, MSc Honorary Fellow Centre for Population Health Sciences The University of Edinburgh Edinburgh, UK

Aziz Sheikh BSc, MBBS, MSc, MD, FRCGP, FRCP, FRCPE Professor of Primary Care Research and Development Co-Director of Centre for Population Health Sciences The University of Edinburgh Edinburgh, UK; Visiting Professor of Medicine Harvard Medical School Harkness Fellow in Health Policy and Practice Brigham and Women’s Hospital Harvard Medical School Boston, MA, USA

Th is edition fi rst published 2014 © 2014 by John Wiley & Sons Ltd.

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Library of Congress Cataloging-in-Publication Data Patient safety and healthcare improvement at a glance / edited by Sukhmeet S. Panesar, Andrew Carson-Stevens, Sarah A. Salvilla, Aziz Sheikh. p. ; cm. Includes bibliographical references and index. ISBN 978-1-118-36136-8 (pbk.) I. Panesar, Sukhmeet S., editor. II. Carson-Stevens, Andrew, editor. III. Salvilla, Sarah A., editor. IV. Sheikh, Aziz, editor. [DNLM: 1. Patient Safety–standards. 2. Medical Errors–prevention & control. 3. Quality of Health Care–standards. 4. Safety Management. WX 185] R729.8 610.28ʹ9–dc23 2014008376

A catalogue record for this book is available from the British Library.

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Cover image: LTH NHS TRUST/SCIENCE PHOTO LIBRARY Cover design by Meaden Creative

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v

Contents

Contributors vii Preface xi Acknowledgements xii How to use your revision guide xiii

The essence of patient safety 1 1 Basics of patient safety 2

Kaveh G. Shojania and Sukhmeet S. Panesar

2 Understanding systems 4 Carl Macrae

3 Quality and safety 6 Ranjit Singh and Gurdev Singh

4 Human factors 8 Ken Catchpole

5 Teamwork and communication 12 Sukhmeet S. Panesar, Sarah A. Salvilla, Martin Bromiley and Jane Reid

6 Reporting and learning from errors 14 Tara Lamont

7 Research in patient safety 16 Lilly D. Engineer and Peter Pronovost

Understanding and interpreting risk 19 8 Risk-based patient safety metrics 20

Elizabeth Allen and Sukhmeet S. Panesar

9 Root cause analysis 24 Donna Forsyth and Sundeep Thusu

10 Measuring safety culture 26 Debra de Silva

Risks to patient care 31 11 Medication errors 32

Sarah P. Slight, Tony Avery and David W. Bates

12 Surgical errors 36 Sukhmeet S. Panesar, Bhupinder Mann, Rajan Madhok and Andrew Carson-Stevens

13 Diagnostic errors 40 Ashley N. D. Meyer, Velma L. Payne, Hardeep Singh and Mark L. Graber

14 Maternal and child health errors 44 Susan Leavitt Gullo and Pierre Barker

15 Slips, trips and falls 47 Susan Poulton and Frances Healey

Part 1

Part 2

Part 3

16 Patient safety in paediatrics 50 Peter Lachman and Jane Runnacles

17 Technology in healthcare and e-iatrogenesis 54 Kathrin M. Cresswell

18 Nosocomial infections 58 Imran Qureshi and Sukhmeet S. Panesar

19 Mental health errors 60 Amar Shah and Kevin Cleary

20 Patient safety in primary care 64 Andrew Carson-Stevens and Adrian Edwards

Quality improvement 67 21 Improving the quality of clinical care 68

Andrew Carson-Stevens and Maureen Bisognano

22 Science of improvement 70 Clifford Norman and C. Jane Norman

23 Model for Improvement 74 Clifford Norman and C. Jane Norman

24 Measurement for improvement 78 Mike Davidge

25 Spread and sustainability of improvement 84 Gareth Parry and Andrew Carson-Stevens

26 Quality improvement tools: visualisation 86 Ashley Kay Childers and David M. Neyens

27 Quality improvement: assessing the system 88 Ashley Kay Childers and David M. Neyens

28 Patient stories in improvement 90 Aled Jones and Andrew Carson-Stevens

29 Leading change in healthcare 92 Helen Bevan

30 Public narrative: story of self, us and now 96 Jay D. Bhatt and Andrew Carson-Stevens

31 Planning an improvement project 98 Lakshman Swamy and James Moses

32 Managing an improvement project 100 Valerie P. Pracilio

33 Quality improvement in psychiatry 104 Peter Klinger, Anthony Weiss and Eric Hazen

34 Quality improvement in intensive care 106 Kevin D. Rooney

35 Quality improvement in obstetrics 108 Gloria Esgebona

36 Quality improvement in surgery 110 Shabnam Hafi z

37 Population health and improvement 112 Mohammed Mustafa and Valerie P. Pracilio

Further reading 114 Index 121

Part 4

vi

vii

Contributors

Elizabeth Allen MPH Postgraduate Student Department of Public Health Imperial College London London, UK

Tony Avery MBBS, PhD, FRCGP Professor of Primary Health Care/Joint Head of Division (Primary Care), Faculty of Medicine and Health Sciences The University of Nottingham Nottingham, UK

Pierre Barker MD Senior Vice President Institute for Healthcare Improvement Clinical Professor Maternal and Child Health Department of Public Health University of North Carolina Chapel Hill, NC, USA

David W. Bates MD, MSc Professor of Medicine Harvard Medical School Professor of Health Policy and Management Harvard School of Public Health; Chief of the Division of General Internal Medicine Brigham and Women’s Hospital; Medical Director, Clinical and Quality Analysis Partner’s HealthCare System Boston, MA, USA

Helen Bevan MBA, DBA Chief Transformation Offi cer Horizons Group NHS Improving Quality Coventry, UK

Jay D. Bhatt DO, MPH, MPA, FACP Associate Physician Health System Clinical Adjunct Lecturer Department of Internal Medicine and Geriatrics Northwestern University Chicago, IL, USA

Maureen Bisognano MS President/CEO Institute for Healthcare Improvement Cambridge, MA, USA

Martin Bromiley Airline Transport Pilot’s Licence Chair, Clinical Human Factors Group North Marston, UK

Andrew Carson-Stevens BSc (Hons.), MB BCh, MPhil Clinical Lecturer in Healthcare Improvement Cochrane Institute of Primary Care and Public Health Cardiff University School of Medicine Cardiff, UK

Ken Catchpole BSc (Hons.), PhD Director of Surgical Safety and Human Factors Research Department of Surgery Cedars-Sinai Medical Center Los Angeles, CA, USA

Ashley Kay Childers PhD, CPHQ Research Assistant Professor Department of Industrial Engineering Clemson University Clemson, SC, USA

Kevin Cleary MBChB, FRCPsych Medical Director Director for Quality and Performance and Consultant

Forensic Psychiatrist East London NHS Foundation Trust London, UK

vii

Kathrin M. Cresswell BSc, MSc, PhD Chancellor’s Fellow The School of Health in Social Science The University of Edinburgh Edinburgh, UK

Mike Davidge BSc, BCom Director, NHS Elect London, UK

Adrian Edwards MBBS, MRCP, MRCGP, PhD Institute Director and Professor of Primary Care Cochrane Institute of Primary Care and Public Health Cardiff University School of Medicine Cardiff, UK

Lilly D. Engineer MBBS-MD, DrPH, MHA Associate Director, DrPH Programme in Health Care

Management and Leadership Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health; Assistant Professor Department of Anesthesiology and Critical Care Medicine Johns Hopkins School of Medicine Baltimore, MD, USA

Gloria Esegbona MBBS, BSc, MSc, MBA, MRCOG Consultant Obstetrician and Gynaecologist & Lecturer Department of Women’s Health Mzati Trust Blantyre, Malawi

Donna Forsyth MSCP, CMIOSH Head of Patient Safety Investigation Department of Patient Safety NHS England London, UK

Mark L. Graber MD, FACP Senior Fellow RTI International Professor Emeritus SUNY Stony Brook School of Medicine Founder and President Society to Improve Diagnosis in

Medicine St. James, NY, USA

Shabnam Hafi z BS, MPH, MD General Surgery Resident Medstar Washington Hospital Center Washington, DC, USA

Eric Hazen MD Instructor in Psychiatry Harvard Medical School; Director, Pediatric Psychiatry Consultation Service Massachusetts General Hospital Boston, MA, USA

Frances Healey RN, PhD Senior Head of Patient Safety Intelligence, Research and

Evaluation Patient Safety Domain NHS England Leeds, UK

Ross W. Hilliard MD Resident, General Internal Medicine The Warren Alpert Medical School of Brown University Providence, RI, USA

Aled Jones PhD, BN (Hons.), RN (Adult), RMN Senior Lecturer School of Healthcare Sciences Cardiff University Cardiff, UK

Peter Klinger MD Instructor in Psychiatry Harvard Medical School Boston, MA, USA

Peter Lachman MD, MMed, MPH, MBBCH, BA, FRCPH, FCP(SA) Deputy Medical Director (Patient Safety) Medical Director Great Ormond Street Hospital Foundation

NHS Trust London, UK

Tara Lamont MSc Scientifi c Advisor NIHR Health Service Delivery and Research (HS&DR)

Programme University of Southampton Southampton, UK

Susan Leavitt Gullo MS, BSN, RN Director Institute for Healthcare Improvement Cambridge, MA, USA

viii

Carl Macrae PhD Senior Research Fellow Centre for Patient Safety and Service Quality Imperial College London London, UK

Rajan Madhok MBBS, MSc, FRCS, FFPH Professor of Public Health Department of Public Health University of Salford Salford, UK

Bhupinder Mann BSc (Hons.), FRCS Consultant Orthopaedic Surgeon Department of Trauma and Orthopaedic Surgery Stoke Mandeville Hospital Aylesbury, UK

Ashley N. D. Meyer PhD Health Science Specialist (Cognitive Psychologist) Veterans Affairs Health Services Research & Development

Center for Innovations in Quality, Effectiveness and Safety Michael E. DeBakey Veterans Affairs Medical Center Houston, TX, USA

James Moses MD, MPH Medical Director of Quality Improvement Department of Quality and Patient Safety Boston University School of Medicine Boston Medical Center Boston, MA, USA

Mohammed Mustafa BSc, MBChB, MRCGP, MSc Clinical Lecturer in Primary Care and Public Health Cochrane Institute of Primary Care and Public Health Cardiff University School of Medicine Cardiff, UK

David M. Neyens PhD, MPH Assistant Professor Department of Industrial Engineering Clemson University Clemson, SC, USA

C. Jane Norman BA, MBA, CQE President Profound Knowledge Products (PKP Inc.) Austin, TX, USA

Clifford L. Norman MA Partner, Associates in Process Improvement (API) Austin, TX, USA

Sukhmeet S. Panesar BSc (Hons.), MBBS, AICSM, MPH, MD Honorary Fellow The Centre for Population Health Sciences The University of Edinburgh Edinburgh, UK

Gareth J. Parry BSc, MSc, PhD Senior Scientist Institute for Healthcare Improvement Cambridge, MA, USA

Velma L. Payne PhD Postdoctoral Fellow (Biomedical Informatics Specialist) Veterans Affairs Health Services Research & Development

Center for Innovations in Quality, Effectiveness and Safety Michael E. DeBakey Veterans Affairs Medical Center Houston, TX, USA

Susan Poulton BM, FRCP Consultant Geriatrician Department of Medicine for Older People, Rehabilitation

and Stroke Portsmouth Hospitals NHS Trust Portsmouth, UK

Valerie P. Pracilio MPH, CPPS Client Services Manager Pascal Metrics Washington, DC, USA

Peter Pronovost MD, PhD, FCCM Sr. Vice President for Patient Safety and Quality Director of the Armstrong Institute for Patient Safety and

Quality Johns Hopkins Medicine; Professor Departments of Anesthesiology/Critical Care Medicine and

Surgery Johns Hopkins University School of Medicine; Professor Department of Health Policy & Management Johns Hopkins Bloomberg School of Public Health; Professor Department of Nursing Johns Hopkins University School of Nursing Baltimore, MD, USA

Imran Qureshi BSc (Hons.), AIEE, MBBS BMJ Cinical Lead for Quality and Safety Specialist Registrar in Medical Microbiology Department of Microbiology St George’s Hospital NHS Trust London, UK

ix

Jane Reid BSc, MSc, PGCEA Professor, Bournemouth University Bournemouth, UK

Kevin D. Rooney MBChB, FRCA, FFICM Professor of Care Improvement Consultant in Anaesthesia and Intensive Care Medicine Institute of Care and Practice Improvement University of the West of Scotland and Royal Alexandra

Hospital Paisley, UK

Jane Runnacles MBBS, BSc (Hons.), MRCPCH, MA Consultant Paediatrician Department of Paediatrics Royal Free London NHS Foundation Trust London, UK

Sarah A. Salvilla BSc (Hons.), MBBS, AICSM, MSc Honorary Fellow The Centre for Population Health Sciences The University of Edinburgh Edinburgh, UK

Amar Shah MBBS, MRCPsych, LLM, PGCMedEd, MBA Associate Medical Director (Quality Improvement) &

Consultant Forensic Psychiatrist East London NHS Foundation Trust London, UK

Kaveh G. Shojania MD Director & Associate Professor of Medicine Centre for Patient Safety University of Toronto Toronto, ON, Canada

Debra de Silva PhD Professor and Head of Evaluation The Evidence Centre London, UK

Gurdev Singh BSc Engg(Alig), MSc Eng, PhD(Birm.) Emeritus Founding Director Patient Safety Research Center State University of New York Buffalo, NY, USA

Hardeep Singh MD, MPH Chief, Health Policy, Quality and Informatics Veterans Affairs Health Services Research & Development

Center for Innovations in Quality, Effectiveness and Safety

Michael E. DeBakey Veterans Affairs Medical Center Houston, TX, USA

Ranjit Singh MA (Cantab.), MB, BChir, MBA Vice Chair for Research Department of Family Medicine State University of New York Buffalo, NY, USA

Sarah P. Slight MPharm, PhD, PGDip Senior Lecturer in Pharmacy Practice School of Medicine, Pharmacy and Health Durham University Durham, UK

Lakshman Swamy BA, MD, MBA Boonshoft School of Medicine Wright State University Fairborn, OH, USA

Sundeep Thusu MEng, MBBS, BDS Clinical Research Fellow Centre for International Child Oral Health Kings College London London, UK

Anthony Weiss BS, MD, MSc Assistant Professor of Psychiatry Harvard Medical School Boston, MA, USA

x

xi

Preface

Healthcare improvement remains the bedrock of any adaptive, learning and high-quality healthcare system. Th e engagement of frontline clinical staff in advancing this agenda is central to ensuring improvements and safety in care delivery, thereby providing the best possible care for the patient. Since the 1990s, there have been concerted eff orts to empower and equip healthcare professionals, carers, students and patients with the knowledge, skills and tools to execute and achieve safer, high-quality, patient- centred care. Th is book is an attempt to synthesise the key lessons learnt and distil these into practical recommendations.

Infl uential reports have raised awareness of healthcare qual- ity and safety in the professional and public conscience. Seminal amongst these have been To Err Is Human, produced by the US Institute of Medicine (IOM), and An Organisation with a Mem- ory, produced by the UK Government’s Chief Medical Offi cer. Th ese reports highlighted that error was routine during the delivery of healthcare and pointed to steps that should be taken to minimise their occurrence and the adverse consequences resulting from these system failures. Th e IOM advises six aims for quality – safety, eff ectiveness, effi ciency, timeliness, patient- centredness and equity. A focus on patient safety has served as a ‘Trojan horse’ to create urgency for change and highlight the major underlying problems in healthcare, and in doing so it has galvanised the importance of seeking all the aims of qual- ity. More recently, the Institute of Healthcare Improvement (IHI) launched Th e Triple Aim that challenges healthcare organisations

to improve patient experience, improve population health and reduce the per capita cost of healthcare in order to optimise health system performance. Building on this approach, many of our contributors have used the lens of patient safety to highlight concerns about and approaches to enhancing the quality of care provision.

Our hope is that this text – which includes contributions from leading international scholars and clinicians in training – will meet the needs of healthcare students and professionals at all stages of their training: from students and junior doctors who have yet to be introduced to the disciplines of healthcare improvement and patient safety to those who want a quick refresher of core concepts and in areas that would be relevant for healthcare professionals in training. Th is refl ects our core belief that all those serving at the ‘coal face’ of healthcare delivery have the capacity to be the barom- eters of the quality and safety of healthcare provision.

Finally, we are optimistic that all those who read this book will in some way – whether by initiating, leading or contributing to collective eff orts – be inspired to move forward the agenda of safe, high-quality, patient-centred care. It is, aft er all, these enduring values that ensure we are fi tting members of ‘the noble profession’ and that we, like every other generation before us, have fulfi lled the charge of ensuring we take stock of preceding eff orts, enrich them and then hand on these quintessential values.

Sukhmeet S. Panesar, Andrew Carson-Stevens, Sarah A. Salvilla and Aziz Sheikh

xii

Acknowledgements

We wish to record our sincere gratitude to our contributors who have taken time away from their many other commit-ments to share their knowledge and insights. Th ese won- derful colleagues have been a real pleasure to work with, and we wish them all the very best in their future endeavours. We owe par- ticular thanks to colleagues at the Institute for Healthcare Improve- ment, Cambridge, USA* who contributed graciously to this book. Any omissions during the editing phase are ours.

We would also like to take this opportunity to thank our fami- lies for their support throughout the conception, gestation and delivery of this book. Th is work is therefore very much also a fruit of their labours, and we hope that they too will take pride in seeing the ideas contained in this book fl ourish.

*Th e Institute for Healthcare Improvement (IHI) (www.IHI.org) is an independent not-for-profi t organization which hosts the IHI Open School (www.ihi.org/openschool).Th e School exists to advance quality improvement and patient safety competencies in the next generation of health professionals.

xiii

How to use your revision guide

Features contained within your revision guide

Each topic is presented in a double-page spread with

clear, easy-to-follow diagrams supported by succinct

explanatory text.

25

C hapter 9 R

oot cause analysis

Patient Safety and Healthcare Improvement at a Glance, First Edition. Edited by Sukhmeet S. Panesar, Andrew Carson-Stevens, Sarah A. Salvilla and Aziz Sheikh © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

What is root cause analysis? Root cause analysis (RCA) is a method of incident investigation.

As such, it is a diagnostic tool rather than a safety solution in itself. RCA allows a systems approach (Chapter 26) to investigation and was selected as the methodology of choice by the National Patient Safety Agency when developing a framework for patient safety investigation in the NHS. The NHS approach aligns well with investigation methods used in healthcare and other high-risk industries across the globe.

Why investigate? The primary aim of patient safety investigation is to learn from inci- dents and to determine what can be done to significantly reduce the likelihood of recurrence; the aim is not to apportion blame.

If, during an investigation, concerns of capability, recklessness or maliciousness arise, the Incident Decision Tree (IDT) should be used to provide guidance on whether and to whom these issues should be referred. Investigation and planned management of these particular concerns should not form part of the patient safety investigation process.

RCA process Investigations can be comprehensive or concise but must always

include the basic elements to help ensure they are thorough, cred- ible and actionable, and represent value for money

Set clear terms of reference and follow them. Secure adequate time and skills, or record and report the impact of constraints

Avoid lots of concise investigations. They can prove false economy 1 Gathering and mapping the information

You have to understand exactly what happened leading up to an incident before you can fully understand why it happened

Investigative interviewing should focus more on listening than on asking questions

Consult the patient and family as part of the investigation; they have a unique perspective and valuable information to share

2 Identifying care and service delivery problems (CDPs and SDPs) – this stage involves identifying all the points at which:

something happened that should not have happened; or something that should have happened did not

3 Analysing problems Using a fishbone diagram (or Ishikawa diagram or cause-

and-effect diagram) as shown in Figure 9.2, place one CDP or

SDP in the head of each fish (not the whole incident), then ana- lyse why that course of action seemed the right thing to do at that time

A few carefully analysed ‘fishbones’ focusing on key CDPs and SDPs will deliver more benefit than many completed quickly

Training in systems thinking and human factors (including error types and biases) will aid impartiality and quality analysis

The root causes are the most significant contributory factors 4. Generating recommendations and solutions

Problems will rarely be resolved for the long term by applying discipline, training and updated procedures alone

Training in improvement science will assist with more effective selection and implementation of solutions

5. Implementing solutions Amalgamate action plans from investigations. This encour-

ages trend analysis and a more cohesive, high-level approach to resolving common issues

Avoid conducting more and more investigations with similar outcomes. Time must be allocated to implementing solutions and monitoring their efficacy

6. Writing the Investigation Report Use an RCA investigation report template to facilitate trend

analysis, audit and shared learning

Effective RCA investigation The components for success in patient safety investigations are the same as those required for successful clinical investigations (Figure 9.1): 1 To avoid the extremes of delayed problem ‘diagnosis’ and resource wastage, triggers or indications for conducting an investi- gation must be correctly identified. 2 To obtain a good-quality, accurate picture of the problem, data gathering must be conducted by those skilled in the process. 3 The findings from the collection of data must be robustly inter- preted and credible conclusions drawn by someone with analyti- cal skills and an understanding of the ‘anatomy, physiology and pathology’ of the issue. 4 To ensure that improvement is achieved and measurable, expert selection, application and monitoring of effective treatment and remedial action are required. 5 If meaningful learning and improvement are expected from incident investigation, there must be organisation-wide support for this process.

Chapter 27 gives an example of a fishbone diagram in use.

9 Root cause analysis Figure 9.1 Steps to an effective root cause analysis (RCA) investigation

Figure 9.2 RCA investigation: fishbone diagram – tool

Good organisational safety culture (infrastructure, resource, support)

Appreciation of the value of,

rationale behind, and indications for

investigation

Appreciation of the value of,

rationale behind, and indications for investigation

Competence in thorough, credible

investigation analysis

Skilled in error wisdom, research,

interpretation and deduction

Skilled in improvement

science

Select and apply effective remedies/ solutions for each

cause ...

and monitor for success

Source: NHS National Patient Safety Agency

Equipment and resource factors

eg

Communication factors

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24

P art 2 U

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Your textbook is full of illustrations and tables.

Patient Safety and Healthcare Improvement at a Glance, First Edition. Edited by Sukhmeet S. Panesar, Andrew Carson-Stevens, Sarah A. Salvilla and Aziz Sheikh © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

74

P art 4 Q

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23 Model for Improvement Figure 23.1 Model for Improvement Figure 23.2 Definition of improvement

Model for Improvement

W to

ov

W ov

Act Plan

DoStudy

Source: Langley G, Moen R, Nolan K et al 2009. Reproduced with permission of John Wiley & Sons Ltd.

Table 23.1 How will we know a change is an improvement? Figure 23.3 The plan–do–study–act cycle

Act Plan

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Source: Langley G, Moen R, Nolan K et al 2009. Reproduced with permission of John Wiley & Sons Ltd.

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1

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3

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12 11 10 9 8 7 6 5 4 3 2 1

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Source: Langley G, Moen R, Nolan K et al 2009. Reproduced with permission of John Wiley & Sons Ltd.

Decrease CAUTI rate

Decrease inappropriate catheter use

Maintain or increase staff satisfaction

Time between CAUTI rate

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Chapter 1 Haemopoiesis / 3

cells are, however,r capable of responding to haemo- poietic growth factors with increased production of one or other cell line when the need arises.

e development of the maturerr cells ,sllecder( granulocytes, monocytes, megakaryocytes and lym- phocytes) is considered further in other sections of

.koobsiht

Bone m arrow s troma e bone marrow forms a suitable environment for

fonoitamrofodnalawener-f-les,lavivrusllecmets erentiated progenitor cells. It is composed of

.)4.1.giF(krowtenralucsavorcimadnaslleclamorts

tseilraeehtsielpmaxenA.aidemdilos-imesni detectable mixed myeloid precursor which gives rise to granulocytes, erythrocytes, monocytes and meg-

gnimrofo-ynoloc(UFCdemretsidnasetycoyraka e bone marrow is also

the primary site of origin of lymphocytes (see erentiate frff om a common

.rosrucerpdiohpmyl e stem cell has the capability for self-ff renewalrr l

-nocsniamerytiralullecworramtahtos)3.1.giF( ere is con-

cation in the system: one stem cell is capable of producing about 106 doolberutam

e precursor

Figure 1.2 Diagrammatic representation of the bone marrow pluripotent stem cell and the cell lines that arise from it. VariousVV progenitor cells can be identified by culture in semi -solid medium by the type of colony they form. It is possible that an erythroid/megakaryocytic progenitor may be formed before the common lymphoid progenitor diverges from the mixed granulocytic/monocyte/eosinophil myeloid progenitor.rr Baso, basophil; BFU, burst-forming unit; CFU, colony -forming unit; E, erythroid; Eo, eosinophil; GEMM, granulocyte, erythroid, monocyte and megakaryocyte; GM, granulocyte, monocyte; Meg, megakaryocyte; NK, natural killer. rr

Pluripotent stem cell

Erythroid progenitors

CFUGEMM Common myeloid progenitor cell

BFUE

CFUE

CFUMeg Megakary- ocyte progenitor

CFUGM Granulocyte monocyte progenitor

CFUEo Eosinophil progenitor

CFUGMEo

CFUbaso

Thymus

CFU-M CFU-G

Common lymphoid progenitor cell

Red cells

Platelets Mono- cytes

Neutro- phils

Eosino- phils

Baso- phils

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Patient Safety and Healthcare Improvement at a Glance, First Edition. Edited by Sukhmeet S. Panesar, Andrew Carson-Stevens, Sarah A. Salvilla and Aziz Sheikh © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

7 Research in patient safety Figure 7.1 Framework for patient safety research

Patient safety research

Domain 5

Evaluating the association between

organisational characteristics and outcomes

Evaluate organisational characteristics that help or hinder

research efforts or patient safety practices

Domain 4

Identifying and mitigating hazards

Use of retrospective and prospective analyses to identify and mitigate

safety hazards at the microscopic level

Domain 3

Assessing and improving culture

Strategies and interventions to improve safety culture and

communication

Domain 2

Translating evidence into practice

Develop and evaluate interventions that increase the extent to which

patient received evidence- based medicine

Domain 1

Evaluating progress in patient safety

Develop valid and feasible measures to evaluate progress to improve

patient safety

16

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Figure 7.2 TRIP model

En ga

ge

Ed uctate Execute Evaluate

1. Summarise the evidence

4. Ensure all patients receive the interventions

3. Measure performance

2. Idenfify local barriers to implementation

Introduction After the To Err Is Human report uncovered the magnitude of the problem of patient safety incidents (more than 98,000 deaths per year due to medical errors), another report by RAND in 2003 revealed that hospitalised patients in the United States received only half of the recommended therapies. The framework for patient safety research and improvements (PSRI) described in this chapter evolved out of the need to bridge the gap between the interventions being implemented and scientific assessment of their success and applicability to similar settings.

The framework has five domains (Figure 7.1): 1 Evaluating progress in patient safety 2 Translating evidence into practice 3 Assessing and improving culture 4 Identifying and mitigating hazards 5 Evaluating the association between organisational characteris- tics and outcomes.

Besides these domains, tools such as simulation, health information technology, quantitative data analysis and others are useful in PSRI. Research and improvement must go hand in hand in order to initiate and sustain improvements. Hospitals must address both the techni- cal work and the adaptive work – the former involves known solu- tions and science, and the latter requires changes in values, attitudes

or beliefs to sustain improvement. A research study could be designed to address one or more of the above domains measuring or evaluating either or both of the technical and adaptive aspects, depending on the scope, timeline and access to data for conducting the study. In a col- laborative team project, the centralised research team would do the technical work and the local team would do the adaptive work.

Evaluating progress in patient safety Measures of patient safety involve two balancing acts: 1 Balancing the desire of a global, although more biased, measure of safety versus a more focused, but less biased (robust), measure. A global measure applicable to all patients (e.g. hospital mortality) has extreme bias due to inadequate risk adjustment and accounting for patient preferences. A specific measure (e.g. central line bloodstream infections) is very robust but targets only a subset of patients. Many specific measures are needed to cover the whole patient population. 2 Finding a balance between a measure that is scientifically sound (valid and reliable) and feasible given the limited resources. Use of relatively easy and inexpensive data sources, such as administra- tive data for measures such as deep venous thrombosis, is feasible but correlates poorly with medical chart review data. In order to address these, it is necessary to:

(a) Reduce the quantity but not quality of data. (b) Consider the validity of a measure at two levels: a. Patient safety domain: If it is an outcome, does it represent an impor- tant aspect of quality, and do either variation in practice among organisations or interventions that improve the outcome demon- strate that it is largely preventable? If it is a process measure, does evidence suggest that the intervention will improve outcomes? b. What study design is used to measure the patient safety domain? Are there well-defined research protocol, data collection tools, well-designed databases, clear quality control plans, and detailed analytic plans? Cluster-randomised designs, a stepped wedge-trial design, or a quasi-experimental (time series) design can be used. As most studies tend to be a pre-post design, it is important to adjust for historical bias or changes in performance over time.

1

Part 1The essence of patient safety

Chapters 1 Basics of patient safety 2 2 Understanding systems 4 3 Quality and safety 6 4 Human factors 8 5 Teamwork and communication 12 6 Reporting and learning from errors 14 7 Research in patient safety 16

Patient Safety and Healthcare Improvement at a Glance, First Edition. Edited by Sukhmeet S. Panesar, Andrew Carson-Stevens, Sarah A. Salvilla and Aziz Sheikh © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

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1 Basics of patient safety Table 1.1 Patient safety terms

Harm

Near miss

Adverse event (AE)

Preventable adverse event

Adverse drug event (ADE)

Patient safety incident (PSI)

Critical incident*

Definition

Any physical or psychological injury or damage to the health of a person, either temporary or permanent Harm is usually classified as no harm, low harm, moderate harm, severe harm or death.

Any patients safety incident that had the potential to cause harm but was prevented, resulting in ‘no harm’ (although this is a term of variable definition).

An event involving unintended harm to a patient that resulted from medical care. Traditionally, the term used for an adverse event was ‘iatrogenesis’.

An event involving patient harm as a result of wrong or inappropriate action (‘error of commission’) or failing to do the right thing (‘error of omission’).

Any incident in which the use of a medication (including prescribed drugs, but also dietary supplements) results in harm to a patient. ADEs include adverse drug reactions (i.e. known side effects that occur even when the medication is used as intended), as well as events in which the drug has been used erroneously (prescribed at the wrong dose, administered in the wrong way etc.). ADEs that result from medication errors are often called ‘preventable ADEs’.

Any unintended or unexpected incident that could have harmed or did harm the patient. This includes ‘near misses’. The term ‘patient safety incident’ is preferred to ‘error’, as the latter has a more negative connotation.

A term first coined in the 1950s and made famous by a classic human factors study by Cooper of ‘anaesthetic mishaps’. Cooper and colleagues brought the technique of critical incident analysis to a wide audience in healthcare, and followed the definition of the originator of the technique. They defined critical incidents as occurrences that are ‘significant or pivotal, in either a desirable or an undesirable way’. Cooper and colleagues (and most others since) chose to focus on incidents that had potentially undesirable consequences. This concept is best understood in the context of the type of investigation that follows, which is very much in the style of root cause analysis. Thus, significant or pivotal means that there was significant potential for harm (or actual harm), but also that the event has the potential to reveal important hazards in the organisation. In many ways, it reflects an expression used in quality improvement circles: ‘every defect is a treasure’ . In other words, these incidents, whether near misses or disasters in which significant harm occurred, provide valuable opportunities to learn about individual and organisational factors that can be remedied to prevent similar incidents in the future.

Patient safety term

*Source: Cooper et al 1978. Reproduced with permission of Wolters Kluwer Health.

Figure 1.1 Frequency of errors in medical care (adverse event rate) Figure 1.2 The Swiss cheese model of how defences, barriers and safeguards may be penetrated by an accidentaly trajectory

USA (3.2–5.4%)

UK (11.7%) Denmark

(9%)

Australia (10.6–16.6%)

New Zealand (12.7%)

Latin America

(10%)

Source: Adapted from de Vries et al 2008. Reproduced with permission of BMJ Publishing Group Ltd. Source: Reason J 2000. Reproduced with permission of BMJ Publishing Group Ltd .

Hazards

Losses

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hapter 1 B asics of patient safety

Introduction As healthcare has become more eff ective, it has also become more complex and involves the use of new technologies, medicine and treatments. We are also now treating a greater proportion of older and sicker patients. Th ese factors, coupled with decreased fi nancial resources in most settings, can result in errors.

Two infl uential reports – To Err Is Human (1999) produced by the US Institute of Medicine and An Organisation with a Memory (2000) produced by the UK Government’s Chief Medical Adviser – heralded the start of the global patient safety movement in the late 1990s. Both reports recognised that error was common during the delivery of healthcare: Figure 1.1 gives estimates of harm globally in hospitals. Th e fi gure of 1 in 10 patients being harmed is com- monly quoted in the world of patient safety.

Th e reports drew attention to the poor performance of health- care, as a sector, worldwide on safety compared to most other high- risk industries. Notably, aviation has shown remarkable and sus- tained improvements in levels of risk to air travel passengers over the last four decades. Both reports called for greater focus on, and commitment to, reducing risks in healthcare. In October 2004, the World Health Organization (WHO) launched a patient safety pro- gramme, in response to a World Health Assembly Resolution (2002) urging WHO and member states to pay the closest possible atten- tion to the problem of patient safety. Its establishment underlined the importance of patient safety as a global healthcare issue. In other countries, specifi c bodies dealing with patient safety were set up: the National Patient Safety Agency (NPSA), which is now part of NHS England; the Agency for Healthcare Research and Quality (AHRQ) in the United States; the Canadian Patient Safety Institute (CPSI); and the Australian Commission on Safety and Quality in Health.

Despite these notable eff orts, the current state of patient safety worldwide is still a source of deep concern. As data on the scale and nature of errors and adverse events have been more widely gath- ered, it has become apparent that unsafe actions are a feature of virtually every aspect of healthcare. Furthermore, there is a paucity of research on the frequency of errors and their associated burden of harm in areas such as primary care and mental health. Reports of the deaths of patients regularly feature in media reports in many countries and undermine public confi dence in health services. Moreover, many events recur, with eff orts to prevent them ineff ec- tive. Th ese could be in part due to a punitive culture of individual blame and system failures. Initial, widely quoted estimates of the number of deaths due to medical error may have been exagger- ated. For instance, a study by Hogan et al. (2012) of 1000 deaths at 10 representative UK NHS trusts found that only 5% were judged preventable, with ‘preventable’ being defi ned as having a greater than 50% probability that better care would have prevented death.

Th ere is also growing concern of late amongst patient safety experts that despite all the eff orts made to date, the patient safety momentum might stall as we have been at it for almost a decade and countless initiatives have been thrown at clinicians who may be overwhelmed.

Defi nitions ‘Patient safety’ can be defi ned as reducing the risk of unnecessary harm associated with healthcare to an acceptable minimum. An ‘acceptable minimum’ refers to current knowledge, resources avail- able and the context in which care was delivered, weighed against the risk of non-treatment or other treatment. Simply put, it is the prevention of errors and adverse eff ects to patients associated with healthcare. Further key defi nitions are given in Table 1.1.

Concepts Th e large-scale technological disasters on oil rigs, nuclear power plants and aviation in the 1980s led to more of a systems-thinking approach to developing safer workplaces and safer cultures. Th e same approach applies to healthcare; it is rare that a doctor or nurse is to blame for an error, but the environment and systems they work in play a strong part. James Reason, an eminent psychol- ogist, developed the ‘Swiss cheese’ model (see Figure 1.2) to explain the steps and multiple factors associated with adverse events. Key points to note in this model are: • Defences, barriers and safeguards exist to protect patients from hazards, such as alarms on syringe drivers or anaesthetists remind- ing surgeons to ensure that an adequate pre-operative work-up of the patient has taken place. Th ese defences can be breached, like the holes in slices of Swiss cheese. However, unlike in the cheese, these holes are continually opening, shutting and shift ing their location. Th e presence of holes in any one ‘slice’ does not normally cause a bad outcome. Usually, this only happens when the holes in many layers momentarily line up to permit a trajectory of acci- dent opportunity – bringing hazards into damaging contact with patients. Th e holes occur due to a combination of active failures and latent conditions • Active failures are the unsafe acts committed by people who are in direct contact with the patient or system. Th ey take a var- iety of forms: slips, lapses, fumbles, mistakes and procedural violations • Latent conditions arise from decisions made by designers, build- ers, procedure writers and top-level management. Th ey can trans- late into error-provoking conditions within the local workplace (e.g. understaffi ng requiring the use of locum doctors). Th ey can also create long-lasting holes or weaknesses in the defences (e.g. the intensive care unit being in a diff erent building from the oper- ating theatre)

Another notable individual, Jens Rasmussen, suggested that errors occurred due to defi ciencies in skills (e.g. asking a junior doctor to perform a laparotomy), observation of rules (e.g. not washing hands before performing a procedure) or knowledge (e.g. being unaware that gentamicin levels need to be checked).

Subsequent chapters will build on the concepts discussed here and equip the reader with the knowledge to identify and rectify potential threats to patient safety.

Patient Safety and Healthcare Improvement at a Glance, First Edition. Edited by Sukhmeet S. Panesar, Andrew Carson-Stevens, Sarah A. Salvilla and Aziz Sheikh © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

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2 Understanding systems Figure 2.1 Healthcare as a complex socio-technical system and system accidents

The delivery of healthcare relies on a complex and wide array of people, activities and technologies

Each of these present opportunities for error, which impact on other parts of the system

Major accidents result from a combination of minor errors spread around these organisational systems

• Protocols • Policies • Procedures • Checklists

• Information technology • Communication systems • Record systems

• Designers • Data analysts • Support staff

• Infrastructure

• Local workplace

• Ward design

• Buildings and estates • Engineers

• Maintenance • Architects

• Universities

• Funders

• Professional bodies

Poorly designed

ward

Mis- specified

policy

• Regulators

• Regulators • Oversight agencies • Professional bodies • Policymakers • Insurers • Commissioners • Educators and trainers

• Procurement • Purchasers • Designers • Manufacturers

• Mistake during manufacture

• Medical equipment • Consumables • Supplies

• Managers • Administrators • Boards • Executives • Safety officers • Clinical leads, etc.

• Doctors • Nurses • Physios • Healthcare assistants

Equipment hard to use

Error using

equipment

Adverse event

• Radiographers • Paramedics • Allied health professionals, etc.

Healthcare professionals:

• Government

Patients

Introduction Modern healthcare organisations are enormously complex (see Figure 2.1). Even the most routine tasks of healthcare now depend on complex systems that connect a multitude of people, activities and technologies. For example, a typical patient in an intensive care unit requires 178 separate actions to be performed for them each day by a range of people, and a patient in their last year of

life will typically be treated by at least 10 specialist doctors. Th e work of any individual healthcare professional is equally depen- dent on a wide range of other factors. Th ese factors include every- thing from eff ective communication with colleagues to the staffi ng levels and resources within an organisation; and from the quality of equipment available locally to the design of wards and infor- mation technology (IT) systems. All of these factors and many

5 C

hapter 2 U nderstanding system

s more contribute to the safety of patients in any given situation. To manage and improve patient safety, it is essential to understand the nature of the complex systems that deliver healthcare, along with the ways that these systems shape – and are shaped by – the work of individuals. Safety improvement eff orts need to be targeted at improving these systems. As human factors expert James Reason has put it: ‘We cannot change the human condition, but we can change the conditions under which humans work’.

From individuals to systems Th ere has been a dramatic shift over the past two decades in how patient safety and error are understood in healthcare. Traditionally, if things went wrong, any investigation and remedial action would focus on the actions of individuals: typically whoever was closest to the adverse event at the time, such as the surgeon who oper- ated on the wrong site or the nurse who miscalculated the drug dose. Th is view has now been replaced by a focus on the safety and reliability of the broader systems within which individuals work. ‘Systems thinking’ has long been established in other safety-critical industries such as aviation. In these industries, decades of detailed investigations have revealed that major accidents are the result of a combination of minor mishaps, inadequacies and errors that occur throughout organisational systems. Th e actions of the individuals who happen to be ‘closest’ to the adverse event are oft en merely the last link in a very long chain of events. Th is systems thinking underpins the entire fi eld of patient safety, and was largely popu- larised in healthcare through two groundbreaking reports: To Err Is Human and An Organisation with a Memory.

Healthcare as a complex socio-technical system Healthcare is a complex socio-technical system, in which even apparently simple tasks can depend on a wide range of social (e.g. psychological, team and managerial) and technical (e.g. equipment, IT and infrastructure) factors. For example, prescribing a medi- cation depends on things such as IT systems that allow access to patient records, communication systems that allow eff ective trans- fer of information between health professionals, purchasing systems that ensure the pharmacy is properly stocked, education systems that ensure health professionals are appropriately trained and reg- ulatory systems that monitor the safety and eff ectiveness of medi- cines. One defi ning feature of complex socio-technical systems is that there are many components and subsystems that must interact with each other to achieve a certain outcome. Th e eff ective inter- action of each of the systems outlined here is essential to the safe prescribing of medications, and each is also a complex system in itself that requires careful management and design. Another defi n- ing feature of complex systems is that many of these components and subsystems are hidden from people working elsewhere in the system. Th e doctor who writes a prescription is unlikely to know much about the purchasing processes in the pharmacy, and yet all of these systems must function eff ectively together to provide safe care.

System reliability Managing the reliability of systems – the ability of a system to routinely perform its function without failure – is a key factor in improving patient safety. Measures of reliability suggest that many

systems in healthcare organisations operate at around 80% reliabil- ity. Th is is an extraordinarily low level. For comparison, if a car was 80% reliable, it would only work 4 days out of 5. Large commercial jets attain on-time reliability rates of around 99.5%. Low levels of system reliability in healthcare include: • Systems that provide patient information for clinical decision making in surgical outpatient clinics operate at around 85% reliability • Within prescribing systems for hospital inpatients, around one in seven prescriptions contain an error. One in fi ve errors would have had serious consequences if not corrected • Processes for ordering surgical theatre equipment operate at around 80% reliability. Half of these failures result in equipment being entirely unavailable

Much work needs to be done to make healthcare systems as reliable as those in other industries. Th is work is advancing rapidly, but it remains at an early stage. Th e Institute for Healthcare Improvement (IHI) uses a three-step model for applying principles of reliability to healthcare systems: • Prevent failure • Identify and mitigate against failure • Redesign the process based on the critical failures identifi ed

Organisational accidents A particular challenge of complex systems is that they can suff er complex and serious breakdowns – ‘organisational’ or ‘system acci- dents’. Minor errors and mishaps in one area of a system are not confi ned to that area, but can impact activities in other areas, oft en in unexpected and dramatic ways. Small mistakes can be ampli- fi ed and have disproportionate eff ects elsewhere in the system. For example, a simple decision about adding a cleaning agent to a hospital’s water system can have severe knock-on eff ects. In 2008, in the United Kingdom, one haemodialysis patient died and four others required blood transfusion aft er a cleaning agent was added to the hospital’s main water supply. It had not been fully realised or properly communicated that the renal unit’s water fi lters could not remove that particular chemical, which passed straight through into the patients’ bloodstream.

Healthcare organisations increasingly rely on a variety of safety defences and controls to assure system safety. Th ese defences aim to prevent errors cascading and aggregating throughout a system in ways that might cause a major system accident. However, these defences themselves can add complexity to the system, which in turn can introduce new risks. Th e water treatment process described here was itself being undertaken to address the safety risks of water-borne infection within the hospital. Safety defences themselves can sometimes introduce new risks, and safety improvements must be carefully designed and assessed from a sys- tem perspective to reduce this possibility. Healthcare depends on a complex, socio-technical system that can be challenging to fully analyse and understand. Improving patient safety requires a deep understanding of the many system interactions and system fac- tors that produce both good and bad outcomes for patients. Every point of potential failure and error is also an opportunity for safety improvement and system redesign.

Patient Safety and Healthcare Improvement at a Glance, First Edition. Edited by Sukhmeet S. Panesar, Andrew Carson-Stevens, Sarah A. Salvilla and Aziz Sheikh © 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.