incident reporting in healthcare and the associated human factors issues sarah scobie head of...
TRANSCRIPT
Incident Reporting in Healthcare and the Associated Human Factors
Issues
Sarah Scobie Head of Analysis and Feedback
Melinda Lyons Human Factors Lead
Presentation today
• The National Reporting and Learning Service
• Healthcare’s achievements in incident reporting
• The Human Factors issues in incident reporting in healthcare
Purpose of the Reporting and Learning System
Learning for safety improvement Hazard and risk identification
New and emerging hazards Highlighting unsolved problems
Supporting reporting organisations with local reporting
Locally, each NHS organisation using data for patient safety and risk management
Reporting and Learning Cycle
•Know what the problems are
•Understand which are most important and why they happen
•Inform solutions and recommendations to prevent future harm
•Assess the difference
How does it collect incidents• Voluntary, confidential national system • Commenced Nov 2003 – over 4 million reports so
far• Covers all health sectors • Every severe and death incident individually
reviewed for national learning• Undergoing continuous improvement
Reporting and Learning System
Secure Database
CleansedDatabase
Data cleansing
Local Risk ManagementSystem
ServiceeForm
NHS Net
WWW
Encrypted traffic
Analysis and feedback
Open AccesseForms
99% incidents
Numbers…
Chart 1: Number of incidents reported and organisations reporting by quarter, October 2003 - December 2008
0
50,000
100,000
150,000
200,000
250,000
300,000
Oct -Dec2003
Jan -Mar2004
Apr -Jun2004
Jul -Sep2004
Oct -Dec2004
Jan -Mar2005
Apr -Jun2005
Jul -Sep2005
Oct -Dec2005
Jan -Mar2006
Apr -Jun2006
Jul -Sep2006
Oct -Dec2006
Jan -Mar2007
Apr -Jun2007
Jul -Sep2007
Oct -Dec2007
Jan -Mar2008
Apr -Jun2008
Jul -Sep2008
Oct -Dec2008
0%
10%
20%
30%
40%
50%
60%
70%
80%
Incidents submitted
Average proportion of trusts reporting per month
Average proportion of trusts reporting per month
Number of incidents reported
April 07 To March 08
April 07 to March 08
April 07 ToMarch 08
… and text
“Cardiac arrest. Patient had mouth full of stomach contents… Both portable suctions not working. Aspiration.”
•Provides essential information for learning from individual incidents•Provides case studies to illustrate points which front-line clinicians relate to•Brings incidents and learning alive
4Full-
scope
20Issues followed up
with mini-scope e.g. NRLS search,
basic literature search
50Incidents & issues considered by
the Weekly Response Group
1500Systematic review of NRLS death & severe incidents
Systematic review of STEIS reportsAd hoc incident / issue reports e.g. coroners, clinicians
1
RLS based products ...
Products & activities
* correct site burr holes in emergency neurosurgery * delayed diagnosis of head injury in patients affected by alcohol * sudden collapse in orthopaedic surgery related to cement and fat embolism * omission of urgent antibiotics in sepsis and neutropaenia * resuscitation in mental health settings, including management of choking and illicit opiate use * diagnostic delay where minor head injuries lead to significant harm in anti-coagulated patients * nasogastric feeding safety in patients with anorexia nervosa * incorrect insertion of central lines * collapse in hospital grounds and the responsibilities of hospital and ambulance service staff * transport for patients in urgent need of transfer between hospitals * correct lens insertion in cataract surgery * patients with arterial disease whose circulation is compromised by anti-embolism stockings * access to emergency gastroscopy out-of-hours * readmission after day surgery * non-invasive ventilation outside high dependency environments * portable syringe drivers in terminal care * female catheters causing urethral trauma if inserted in males * Awareness due to lack of non-return valve on giving set (TIVA) * administration errors when medication supplied in compliance aids * safe storage of emergency medications in staff response vehicles * HIV screening and treatment in maternity care * management of oxygen therapy * over-provision of intravenous fluids * wrong side burr holes / craniotomy *
National Institute for Clinical
Excellence (NICE)
Resuscitation Council
National Confidential Enquiry into Patient Outcome and Death
(NCEPOD)
Medicines & Healthcare products
Regulatory Agency (MHRA)
Royal College of Anaesthetists
Ongoing projects for clinical teams
Royal College of
Ophthalmologists
Rapid Response Report
Chest drains• Trigger incident – patient died from perforated liver
after drain inserted Feb 08• RLS database : 12 reported patient deaths + 15
serious harm Jan 05 - March 08 • + 9 serious incidents from MHRA re problems with
equipment • Go back to trusts for more information – RCAs• Key learning – junior doctors without supervision, poor
positioning (without ultrasound), unfamiliar with equipment
Actions• Report May 2008 developed
with input of chest physician/British Thoracic Society
• Clear actions including use of ultrasound (NICE 2006)
• Longer term action includes work by MHRA (concern re length of dilators) and revised clinical guidelines from British Thoracic Society
• Evaluation in 2009 but informal feedback suggests widespread support eg purchase of portable ultrasounds
Challenges
Under-reporting
Analytic methods Priority setting
Actionable learning
Closing the loop
What are the biggest challenges?
• “Extracting the important data - what are the real issues that impact on safety, how can we analyse in a meaningful manner, other than simple 'number' crunching.”
• “Relies on events being reported; easy to miss recovered incidents as staff see it as part of their skill to do so - may consider don't have time to then report, especially if no harm to the patient.”
• “Conflicting demands on existing resources, in respect of support staff, reporters etc”
Direction
• Embedding and engaging• Trial of specialty reporting• Data mining
And not to forget those human factors….• Human Factors in the analysis• Awareness of Human Error• Awareness of Equipment design• Awareness of Workload• Supporting clinical decisions and education about
biases
And not to forget those human factors….• Human Factors in the solutions
• Equipment and Environment Design• Training and Education• Protocols and Checklists• Supporting a “just culture”
And not to forget those human factors….
• Education of the value of human factors (it’s not just teamwork!)
• The role in implementation and stakeholder engagement
• Recognition of human errors – even in the most well-meaning of patient safety efforts…
• Validation of changes / decisions – did they really make it more safe?
