learning from incidents keith reynolds risk manager south warwickshire general hospitals nhs trust
TRANSCRIPT
Learning from incidentsLearning from incidents
Keith ReynoldsKeith Reynolds
Risk ManagerRisk ManagerSouth Warwickshire General Hospitals NHS TrustSouth Warwickshire General Hospitals NHS Trust
IncidentIncident
Unplanned event which resulted or Unplanned event which resulted or had the potential to result in injury, had the potential to result in injury, loss or damageloss or damage
Incident exampleIncident example
In 1998 the patient attended A+E having In 1998 the patient attended A+E having been stung by a wasp. Anaphylactic been stung by a wasp. Anaphylactic shock resulted and she was admitted to shock resulted and she was admitted to hospital for 6 days. One particular hospital for 6 days. One particular symptom was a period of blindness. symptom was a period of blindness. Drugs prescribed include IV adrenaline, Drugs prescribed include IV adrenaline, piriton, maxalon, and cyclizine.piriton, maxalon, and cyclizine.
AllegationsAllegations
A 1mg dose of adrenaline was given in A 1mg dose of adrenaline was given in one shot IV leading to a non-one shot IV leading to a non-haemorrhaging infarct in the brain haemorrhaging infarct in the brain causing ischaemia affectingcausing ischaemia affecting eyesight eyesight and causing amnesia amongst other and causing amnesia amongst other symptoms. Claimant no longer able to symptoms. Claimant no longer able to work.work.
CostCost
This case estimated at £480,000This case estimated at £480,000 Total cases involving the Trust £10 Total cases involving the Trust £10
millionmillion Total cases settled last year in the Total cases settled last year in the
NHS £250 millionNHS £250 million
Incident InvestigationIncident Investigation
““Rather than being the main instigators Rather than being the main instigators of an accident, operators tend to be of an accident, operators tend to be the inheritors of latent failures the inheritors of latent failures created at the blunt end. Their part is created at the blunt end. Their part is usually that of adding the final garnish usually that of adding the final garnish to a brew which has been long in the to a brew which has been long in the cooking.”cooking.”
Reason: Reason: Human Reliability (1988)Human Reliability (1988)
Clinical care
The environment of care
Financial resources
CLINICAL GOVERNANCE
ORGANISATIONAL CONTROLS
FINANCIAL CONTROLS
Organisational Assurances
(Annual Report)
Clinical Assurances (Clinical Governance
Report/Annual Report)
Financial Assurances
(Annual Accounts)
Risk management Risk management and corporate and corporate governancegovernance
National Health Service National Health Service initiativesinitiatives
AS/NZS 4360:1999, Risk ManagementAS/NZS 4360:1999, Risk Management Clinical governanceClinical governance Controls assuranceControls assurance Clinical Negligence Scheme for TrustsClinical Negligence Scheme for Trusts
– risk poolrisk pool– risk management standards with risk management standards with
discountsdiscounts
CLINICAL NEGLIGENCE SCHEME FOR CLINICAL NEGLIGENCE SCHEME FOR TRUSTS - RISK STANDARDSTRUSTS - RISK STANDARDS
Clinical RM strategyClinical RM strategy Defined Board Defined Board
responsibilityresponsibility Clinical RMClinical RM Incident reporting Incident reporting
systemsystem Rapid follow-up of major Rapid follow-up of major
incidentsincidents Complaints managementComplaints management Patient information on Patient information on
risks and benefitsrisks and benefits
Standards for medical Standards for medical record keepingrecord keeping
Induction arrangements Induction arrangements for clinical stafffor clinical staff
Clinical risk Clinical risk management systemmanagement system
Clinical care - guidelines, Clinical care - guidelines, accountability etcaccountability etc
Maternity care standards Maternity care standards for high risk pregnancyfor high risk pregnancy
RM STANDARDS (cont.)RM STANDARDS (cont.)
Standards for medical record Standards for medical record keepingkeeping
InductionInduction Clinical risk management systemClinical risk management system Clinical care - guidelines, Clinical care - guidelines,
accountability etcaccountability etc Maternity careMaternity care
Controls Assurance Controls Assurance standardsstandards
Risk mgt. systemRisk mgt. system Buildings, land,plant and Buildings, land,plant and
non-medical equipmentnon-medical equipment Catering and food Catering and food
hygienehygiene Contracts & control of Contracts & control of
contractorscontractors Emergency preparednessEmergency preparedness Environmental Environmental
managementmanagement Fire safetyFire safety
Health and safety mgt.Health and safety mgt. Human resourcesHuman resources Infection controlInfection control IM&TIM&T Medical devices mgt.Medical devices mgt. Medicines managementMedicines management Professional and product Professional and product
liabilityliability Records managementRecords management SecuritySecurity TransportTransport Waste managementWaste management DecontaminationDecontamination
TM T
Trust Board
C lin icalG overnanceCom m ittee
Contro lsAssuranceCom m ittee
Audit and R iskG roup
D irectorateCorporate
G overnancecom m ittees
Specialist clinicalgovernance committees
Research and ethicscom m ittee
Drug and therapeuticscom m ittee
Practices and procedurescom m ittee
Specia listD irectoratecom m ittees
Specialist controlsassurance committees
Health and Safety com m itteeSecurity groupW aste group
Infection control com m itteeM edical records group
CIPB
Finance and auditcom m ittee
Internal audit
M anagem entassurance
Independentassurance
Corporate GovernanceMay 2000
Everyone makes Everyone makes mistakes…..mistakes…..
0100020003000400050006000
£ millions
1975 1980 1985 1990 1996 2001
Year
Clinical litigation costs in UK
Claims against the NHSClaims against the NHS
Current claims against the NHS - number
16,660
8,300
Current claims against the NHS - cost/ £billions
4
2
Obstetrics Others
Source: NHS Litigation Authority
Obstetric claims against Obstetric claims against the NHSthe NHS
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Cere
bral palsy
Fata
lity
Erbs
palsy
Brain da
mag
e
Unn'sa
ry pain
Other
No.Cost/ £millions
Even locally…….Even locally…….
0
1
2
3
4
5
6
7
Cost
/£m
illio
ns
obs
mid
wif
surg
ort
h
a/e
med en
t
pae
d
gyn
onco
l
vasc
anae
s
ophth
hae
m itu
uro
l
gas
tro
den
t
Speciality
Clinical litigation by speciality SWGH 1990-1999
Even locally…...Even locally…...
05
10152025
No.
a/e
obs
surg
orth
mid
wif
med gyn
ent
paed
opht
h
onco
l
urol
vasc
gast
ro
dent
radi
o
itu
haem
anae
s
Speciality
Clinical litigation cases by speciality SWGH 1990-1999
At every level……..At every level……..
020406080
No.
con
sho
reg
mid
w
stnur
sist
er
lcon
sfgd
sreg
lsho
ther
ap
Occupation
Clinical litigation claims by occupation SWGH 1990-1999
Why did it happen…...Why did it happen…...
0
5
10
15
20
25
30
35
No.
Dia
gnosi
s
Dam
age
Superv
isio
n
Feta
l H
eart
rate
Conse
nt
Follow
-up
a-n
ata
labnorm
ality
Adm
dela
y
Medic
ati
on
Wro
ng s
ite
fore
ign b
ody
Com
pete
nce
Oth
er
Costs of clinical incidentsCosts of clinical incidents
Intangible losses
Hidden
losses
Tangible
losses
Reputation, staff morale,
defensive working
Increasedlengthof stay, delayin treating other
patients
Injury,disease,death,litigation
1
29
300
Source: HSE (1997)
Typical total costs of a Typical total costs of a claimclaim
Lacerations, minor scars---------£0-10kLacerations, minor scars---------£0-10k Missed/delayed fractures--------£10-25kMissed/delayed fractures--------£10-25k Surgery to remove surg. mat.---£25-50kSurgery to remove surg. mat.---£25-50k Damaged organs, footdrop-----£50-100kDamaged organs, footdrop-----£50-100k Fail sterilisation = live birth----£100k-Fail sterilisation = live birth----£100k-
1.13m1.13m Paraplegia, blindness-----------£250-500kParaplegia, blindness-----------£250-500k Quadriplegia, brain damage--£500k-4.5mQuadriplegia, brain damage--£500k-4.5m Death---------------------------------£10-250kDeath---------------------------------£10-250k
Adverse incidentsAdverse incidents
Adverse incidents occur in 10% of Adverse incidents occur in 10% of hospital admissionshospital admissions
37% of these result in disability37% of these result in disability 8% result in death8% result in death
Source: Vincent, Neale and Woloshynowych BMJSource: Vincent, Neale and Woloshynowych BMJ 2001;322:517-519 ( 3 March )2001;322:517-519 ( 3 March )
Comparative SWGH Comparative SWGH figures using UCL studyfigures using UCL study
38,000 in-patient episodes pa 38,000 in-patient episodes pa (including Day Case) of which:(including Day Case) of which:– 3800 inpatient adverse incidents3800 inpatient adverse incidents– 950 moderate or permanent 950 moderate or permanent
impairmentimpairment– 304 deaths304 deaths
Incident investigation Incident investigation findingsfindings
Under-reporting of incidentsUnder-reporting of incidents RecordsRecords
– indecipherableindecipherable– undated/not timedundated/not timed– no authorno author– non-existentnon-existent– no reason for treatment/testno reason for treatment/test
Causes of incidents Causes of incidents (NHSLA)(NHSLA)
Failure to monitor, observe, or actFailure to monitor, observe, or act Delay in diagnosisDelay in diagnosis Incorrect risk assessment (for Incorrect risk assessment (for
example, of suicide or self harm)example, of suicide or self harm) Inadequate handoverInadequate handover Failure to note faulty equipmentFailure to note faulty equipment Failure to carry out preoperative Failure to carry out preoperative
checkschecks
Causes of incidentsCauses of incidents
Not following an agreed protocol Not following an agreed protocol (without clinical justification)(without clinical justification)
Not seeking help when necessaryNot seeking help when necessary Failure to supervise adequately a junior Failure to supervise adequately a junior
member of staffmember of staff Incorrect protocol appliedIncorrect protocol applied Treatment given to incorrect body siteTreatment given to incorrect body site Wrong treatment givenWrong treatment given
Incident InvestigationIncident Investigation
Proximate causesProximate causes Sub-proximate causesSub-proximate causes Root causesRoot causes
Root causes reveal areas which if Root causes reveal areas which if changed reap the greatest benefit.changed reap the greatest benefit.
Incident exampleIncident example
68 year old female patient brought to A/E 68 year old female patient brought to A/E by ambulance with non-descript chest by ambulance with non-descript chest pain. Admitted to a medical ward and pain. Admitted to a medical ward and treated for thrombosis. Heparin written treated for thrombosis. Heparin written up for 24 hour period. Delayed KCCT up for 24 hour period. Delayed KCCT test showed hypersensitivity to test showed hypersensitivity to heparin. Blood not clotting. Patient heparin. Blood not clotting. Patient had lung haemorrhage, subsequently had lung haemorrhage, subsequently arrested and died.arrested and died.
Proximate causesProximate causes Differential diagnosisDifferential diagnosis Patient weakened by morphinePatient weakened by morphine Lung haemorrhageLung haemorrhage Sensitivity to heparinSensitivity to heparin Sensitivity not detectedSensitivity not detected Prolonged use of heparinProlonged use of heparin No protamin administeredNo protamin administered
Sub-Proximate CausesSub-Proximate Causes
KCCT test not carried out in KCCT test not carried out in adequate timeadequate time
Protocol for heparin administration Protocol for heparin administration not followednot followed
Conflicting advice in use of Conflicting advice in use of ProtaminProtamin
Root CausesRoot Causes Procedure for receiving Telephoned lab Procedure for receiving Telephoned lab
results LTAresults LTA Lack of advanced diagnostic servicesLack of advanced diagnostic services Inadequate Portering staff at the weekendInadequate Portering staff at the weekend Procedure for urgent sample test LTAProcedure for urgent sample test LTA Training, supervision and information for Training, supervision and information for
Junior Doctors LTAJunior Doctors LTA Protocol for Protamin not communicatedProtocol for Protamin not communicated
Incident InvestigationIncident Investigation
““Any accident is more Any accident is more tragic if human tragic if human experience is none the experience is none the richer for it.”richer for it.”
A.D. Craven: A.D. Craven: Safety and Accident Prevention in Chemical OperationsSafety and Accident Prevention in Chemical Operations
RecommendationsRecommendations
Review clinical incidentsReview clinical incidents Make accurate, timely, identifiable, Make accurate, timely, identifiable,
legible recordslegible records Review the patient when making Review the patient when making
potentially serious interventionspotentially serious interventions Act within level of competenceAct within level of competence Keep up to dateKeep up to date