The Future of Patient SafetySeeing safety through the patient’s eyes

Rene Amalberti & Charles Vincent

Department of Experimental Psychology, Nuffield Department of Surgical Sciences

University of Oxford

Overview

Our current view of patient safety Broadening our view of harm: through the patient’s

eyes Starting from reality: 5 levels of care Safety along the patient journey Models of safety across settings Implications and directions

– Models of event analysis– The nature of safety interventions– The challenge of home care

The nature of harm

Incidents, accidents Adverse events Near misses, close calls etc. Relatively circumscribed events

– Hospital based (for the most part)– They have a history, but a short one– Observed by healthcare professionals

Incidents within a patient journey(Healthcare professionals’ view)

Good care + incidents

Shekelle et al, 2013

Targeted at events

Aim is to optimise reliability of basic procedures

Patient safety outside the hospital?

Little developed Little traction?

– Lack of interest?– Lack of infrastructure?– No incentives?– Wrong language and concepts?

I Broadening our view of harmThrough the patient’s eyes

Patient harm happens in every healthcare setting: at home in convalescence, in an operating room under anaesthesia, at the lab getting

blood drawn, in the hospital corridor lying alone on a stretcher ……

Harm may result from wrong or missed diagnosis, scheduling delay, poor hygiene, mistaken identity, unnoticed symptoms, hostile behaviour, device malfunction, confusing instructions, insensitive language and hazardous

surroundings.

The trajectory of harm begins with the unexpected experience of harm arising from or associated with the provision of care, including acts of both commission and omission……... The patient may experience harm during the episode of care when the failure occurred, or later, after some time has

passed. Harm as it is first endured may evolve, transform and spread (Canfield, 2013)

Harm through the patient’s eyes

Harm is conceived very broadly encompassing both serious disruption of treatment and distressing events.

Harm includes serious failures to provide appropriate treatment as well as harm that occurs over and above the treatment provided.

Harm is seen not in terms of incidents but as a trajectory within a person’s life.

A broader view of harm

Treatment specific harm Harm due to over treatment General harm from healthcare Harm due to failure to provide appropriate treatment Harm due to failed or inadequate diagnosis Psychological harm and feeling unsafe Harm due to neglect and dehumanisation

Explore dimensions of harm in each setting

Hospital acquired syndromes in care of the elderly– Dehydration – Malnutrition– Delirium – Depression – Pressure sores – Incontinence

II Starting from realityFive levels of care

Are our clinical systems and processes reliable?

• Measuring and testing reliability: the WISER study –– Clinical information availability at the point of decision

making– Prescribing for hospital inpatients– Equipment in theatres– Equipment for inserting IV lines– Handover between wards

• Past medical history• Referral letter/other specialty letter• Discharge summary • Current medication• Radiology/imaging results• Diagnostic test results• Procedure notes/anaesthetic record • Electrocardiogram (ECG) report• Blood results

I’m looking for...

15% of patients with missing information

across 3 hospitals

Equipment availability in operating theatres

19% of operations with one or more equipment

problem

Quality ambition- Optimal care(almost never reached)

5 Care where harm undermines any benefits obtained

Threat to health

OPTIMAL BENEFIT

INCREASED RISK OF HARM

1 The care envisaged by standards

3 Unreliable care/ poor qualityThe patient escapes harm

2 Compliance with standards- ordinary care with imperfections

4 Poor care with probable minor harm but overall benefits

Area of Safety

Area of Quality

5 levels of care

‘The illegal normal’

Quality ambition- Optimal care(almost never reached)

5. Care where harm undermines any benefits obtained

Threat to health

OPTIMAL BENEFIT

INCREASED RISK OF HARM

1The care envisaged by standards

3. Unreliable care/ poor qualityThe patient escapes harm

2. compliance with standards- ordinary care with imperfections

4. Poor care with probable minor harm but overall benefits

Interventions to optimise reliability

Interventions to

reduce harm

The same thing?

III Safety along the patient journeyThrough the patient’s eyes

IV Managing safety in different contexts

No system

beyond this point

10-2 10-3 10-4 10-5 10-6

Civil Aviation

Nuclear Industry

Railways

Chartered Flight

Drilling Industry

Chemical Industry (total)

Fatal risk

Anesthesiology ASA1

Innovative medicine (grafts, oncology …) ICU Trauma centers

Very unsafe Ultra safe

Professional fishing

Three Contrasted Safety models

Unsafe Safe

Himalayamountaineering

Combat A/C, war time

Medical risk (total)

Scheduled surgery Chronic care

Radiotherapy, BiologyBlood transfusion

Finance Fire FightingFood Industry

Processing Industry

2014

Embracing risk: ultra-resilient:

Taking risks is the essence of the profession

Cult of champions and heroes Power to the experts – ‘give me

the best tools to survive’ Success analysis more

important than accident analysis

Training. Experts talk to juniors, acquisition of expertise, understanding own limitations

Managing risk: high reliability model

Risk in not sought out but is inherent in the profession

Group intelligence and adaptation

Mutual protection team members. Suspicion of simple explanations

Training and safety focused on adaptability and flexibility of procedures

Avoiding risk: ultra safe

Risk is excluded as far as possible

Procedures & supervisory systems

Priority given to prevention Strong regulatory control Training focused on rigorous

procedures and management of workload

Models of safety within healthcare

Embracing risk - Ultra resilient– Treatment of cancers with poor prognosis, military

medicine, major trauma surgery Managing risk – HRO model

– Elective surgery, obstetrics Ultra-safe

– Laboratory medicine, blood products, radiotherapy

A model of safety for care in the home?

?

?

?

Rethinking patient safety

Redefining patient safety

Patient safety is the art of controlling risks of time to minimize harm (isolated or cumulative) in relation to benefits

The reduction of all incidents and minor harm is a secondary, though still desirable, objective.

Analysis should focus on understanding the ‘EVENT’ JOURNEY’: the sum of events positive and negative that make at end the care successful or tragic

Neither total compliance, nor zero harm

With this definition, patient safety is: – Not a ‘zero default’ approach with total elimination of

any harm or incidents. – Not primarily a ‘process-driven’ approach aimed at

total compliance with procedures, whatever the value of these procedures

The nature of safety interventions

Interventions need to be targeted at the real world not at the ideal world of regulations and standards

Optimal interventions will differ according to context There is a limit to optimising reliability Focus on risk control and mitigation as well as on error

prevention and causation Stronger focus on organisational interventions and

building foundations of safety