the science of patient safety – dr john fitzsimons · 2019-04-09 · dr john fitzsimons • dr...
TRANSCRIPT
![Page 1: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/1.jpg)
Building an Irish Network of Quality Improvers
QI TALK TIME
The Science of Patient Safety – Dr John Fitzsimons 22nd February 2017 1-2 pm
Connect Improve Innovate
The Science of Patient Safety – Dr John Fitzsimons 22nd February 2017 1-2 pm
![Page 2: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/2.jpg)
Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes
Hospital, Drogheda and Clinical Director with the HSE QID. He trained in paediatrics in Ireland, Australia and the UK.
• John trained as a Patient Safety Officer with the Institute of Healthcare Improvement (IHI) in 2009 and became a fellow of the Improvement Faculty at the NHS Institute for Improvement & Innovation for two years.
• In September 2013 he commenced a half-time secondment as Clinical Director for Quality Improvement with QID.
• He was chair of the group that published the NCEC Paediatric Early Warning System Guideline in 2015.
• He is a course co-director for the HSE/RCPI Diploma in Leadership and Quality in Healthcare.
Dr John Fitzsimons
![Page 3: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/3.jpg)
• Interactive
• Sound
• Chat box function • Comments • Questions • Ideas
• Q&A at the end
• Attendance certs
Tips for successful webex
![Page 4: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/4.jpg)
Building an Irish Network of Quality Improvers
QI TALK TIME
The Science of Patient Safety – Dr John Fitzsimons 22nd February 2017 1-2 pm
Connect Improve Innovate
The Science of Patient Safety
![Page 5: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/5.jpg)
Outcomes At the end of this webinar you will be able to…
• Describe the evolution of patient safety as a science
• Discuss new ideas in patient safety including HRO’s, human factors, safety culture & Safety II.
• Apply methods to improve measure and monitor safety in your work place
![Page 6: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/6.jpg)
Is patient safety a science?
![Page 7: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/7.jpg)
Organisational Safety
© Erik Hollnagel, 2009
IT Revolut ion
Three ages of indust rial safet y
2000195019001850
1931Indust rial accident
prevent ion
1893Railroad Safet y Appliance Act
1769Indust rial Revolut ion
1961Fault t ree analysis
Age of t echnology
1979Three Mile
Island
Age of human fact ors
2003Columbia
Age of safet y managementThin g s c an g o Th in g s c an g o
w r o n g bec ause w r o n g bec ause Or gan isat io n s f ailO r gan isat io n s f ail
2009 AF 447
![Page 8: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/8.jpg)
State of the art: Patient Safety 2013
Shekelle PG et al. Annals of Internal Medicine. 2013 Mar;158(5_Part_2):365-368.
![Page 9: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/9.jpg)
A new idea?
Kieran Walsh. International Journal for Quality in Health Care 2009; Volume 21, Number 3: pp. 153–159
![Page 10: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/10.jpg)
First, do no harm! Hippocrates, c. 460 – c. 370 BC
![Page 11: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/11.jpg)
Harvard Medical Practice Study NEJM 1991
![Page 12: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/12.jpg)
IOM Reports
To Err is Human
1999
Crossing the Quality Chasm
2001
![Page 13: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/13.jpg)
A Way to Patient Safety
Building a Culture of Patient Safety 2008
A Vision for Patient Safety
“Knowledgeable patients receiving safe and effective care from skilled professionals in appropriate environments with assessed outcomes”
![Page 14: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/14.jpg)
Irish National Adverse Events Study Rafter et al. BMJ Qual Saf. 2016 Feb 9.
![Page 15: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/15.jpg)
What is patient safety?
“The avoidance, prevention and amelioration of adverse
outcomes or injuries stemming from the process of
healthcare”
Charles Vincent
![Page 16: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/16.jpg)
Error & Harm
Error (commission & omission)
• Slips
• Lapses
• Mistakes
Harm
![Page 17: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/17.jpg)
Error
“…a generic term to encompass all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency.”
Dr. James Reason
![Page 18: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/18.jpg)
Harm
“An injury arising from the process of healthcare that you would not wish to happen to you or a loved one”
![Page 19: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/19.jpg)
Categorising Harm
Category A Error potential
Category B to D Error no harm
Category E to H Harm occurs with increasing injury & need for intervention
Category I Death
![Page 20: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/20.jpg)
Error & Harm
Error
Harm
Non-preventable
Preventable
![Page 22: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/22.jpg)
So, who is responsible?
![Page 23: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/23.jpg)
![Page 24: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/24.jpg)
A Systems Perspective
“ Rather than being the main instigators of
an accident, operators tend to be the
inheritors of system defects…..
their part is that of adding the final garnish
to a lethal brew that has been long in the
cooking.”
James Reason
![Page 25: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/25.jpg)
Patient safety view of systems
Environment
Organisation
Practitioners & Patients
Tools & Technology
Tasks
Thanks to Matt Scanlon
![Page 26: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/26.jpg)
Swiss Cheese Model
James Reason
![Page 27: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/27.jpg)
Organisational Accident Model
Harm
Management decisions
& Organisational
processes
Environment factors
Team factors
Staff factors
Task factors
Patient factors
Unsafe acts
Errors
Violations
Organisation & Culture
Contributory factors
Care delivery problems
Defences & Barriers
Latent failures
Active failures
Adapted from Charles Vincent
![Page 28: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/28.jpg)
Safety Solutions
“We cannot change the human condition, but we can change the conditions under which humans work”
James Reason
![Page 29: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/29.jpg)
Innovation in Patient Safety https://hbr.org/2016/08/the-next-wave-of-hospital-innovation-to-make-patients-safer
![Page 30: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/30.jpg)
Safety Solutions Engineering & System
Leadership, Risk Management &
Organisational Culture
Design, redesign & improvement
- Technology
- Standardisation
- Bundles
- Checklists
- Forcing functions
- Redundancies
![Page 31: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/31.jpg)
Innovation in Patient Safety https://hbr.org/2016/08/the-next-wave-of-hospital-innovation-to-make-patients-safer
![Page 32: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/32.jpg)
Why don’t they just do it like we told them?
Work as imagined Vs. Work as is
Violations
• Routine
• Necessary
• Optimising to reckless
![Page 33: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/33.jpg)
PERFORMANCE
ACCIDENT
Systemic Migration to Boundaries
VE
RY
UN
SA
FE
SPA
CE
The posted
speed limit
is
50 mph- the
‘legal’
space
Belief
Systems.
Life Pressures
INDIVIDUAL BENEFITS
Driving 60
mph- the
‘Illegal-
normal’
space
Driving
80 mph –
the
‘illegal-
illegal’
space (for
almost all
of us!) Perceived
vulnerability
R. Almaberti
![Page 34: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/34.jpg)
PERFORMANCE
ACCIDENT
Systemic Migration to Boundaries
VE
RY
UN
SA
FE
SPA
CE
Handwashing,
every patient,
every time
Belief
Systems.
Life Pressures
INDIVIDUAL BENEFITS
Hand
washing
when patient
has MRSA
Only
wash
hands on
audit
days
Perceived
vulnerability
R. Almaberti
![Page 35: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/35.jpg)
Human Factors
Acnordicg to resraech at Cambrdige Unrveisity, it deosn't mettar in waht oedrr the lertets in a wrod are. The olny ipmortant tihng is taht the fisrt and lsat letter be in the rgiht palce.
The rset can be a tatol mses and you can slitl raed it withuot prlboem. Tihs is becuase the huamn mnid deos not raed eevry letter by itslef, but the wrod as a whloe.
![Page 36: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/36.jpg)
The Human Factor
• We learn from recognising our errors
• We have good days & bad days
• We get tired, sore and sick
• We have cognitive limitations
• We don’t always say what we mean
• We have lives outside of work
![Page 37: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/37.jpg)
Cognitive Error
![Page 38: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/38.jpg)
Dual process model for decision making.
Croskerry P et al. BMJ Qual Saf doi:10.1136/bmjqs-2012-
001712
Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.
![Page 39: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/39.jpg)
Reducing Cognitive Error
• Enhance knowledge and awareness of cognitive biases
• Enhance professional reasoning, critical thinking and decision-making skills
• Enhance work system conditions, workflow design that affect cognition
![Page 40: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/40.jpg)
Human Factors Solutions
• HALT - Hungry
- Angry
- Late
- Tired
• Sterile Cockpit
![Page 41: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/41.jpg)
Theory of High Reliability
Sutcliffe KM, Paine L, Pronovost PJ
Re-examining high reliability: actively organising for safety
BMJ Qual Saf Published Online First:21 March 2016. doi: 10.1136/bmjqs-2015-004698
![Page 42: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/42.jpg)
High Reliability Organisations 5 key Features
• Preoccupation with failure
• Reluctance to simplify
• Deference to expertise
• Sensitivity to operations
• Resilience
![Page 43: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/43.jpg)
Team Learning
After Action Review
1. What was expected to happen?
2. What actually happened?
3. Why was there a difference?
4. What can we learn to improve?
![Page 44: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/44.jpg)
High Reliability Organisations 5 key Features
• Preoccupation with failure
• Reluctance to simplify
• Deference to expertise
• Sensitivity to operations
• Resilience
![Page 45: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/45.jpg)
Paediatric Early Warning System
Team work & Communication
Decision & Response support
Situation Awareness
Family Involvement
PEWS observation
chart & score
![Page 46: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/46.jpg)
High Reliability Organisations 5 key Features
• Preoccupation with failure
• Reluctance to simplify
• Deference to expertise
• Sensitivity to operations
• Resilience
![Page 47: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/47.jpg)
Simulation
![Page 48: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/48.jpg)
Simulation
![Page 49: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/49.jpg)
High Reliability Organisations 5 key Features
• Preoccupation with failure
• Reluctance to simplify
• Deference to expertise
• Sensitivity to operations
• Resilience
![Page 50: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/50.jpg)
What is Situation Awareness?
![Page 51: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/51.jpg)
The ”It” Factor
Situation Awareness
Perception Gather the information
Comprehension Recognise and Understand
Projection Anticipate/Predict/Mitigate/Escalate
![Page 52: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/52.jpg)
Situation Awareness Tools Safety Pause ISBAR for Clinical Handover
![Page 53: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/53.jpg)
![Page 54: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/54.jpg)
A serious safety event has occurred.
Click here for details.
With thanks to Stephen Meuthing CCHMC
![Page 55: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/55.jpg)
High Reliability Organisations 5 key Features
• Preoccupation with failure
• Reluctance to simplify
• Deference to expertise
• Sensitivity to operations
• Resilience
![Page 56: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/56.jpg)
Great Teams Rescue
J Thorac Cardiovasc Surg. 2000 Apr;119(4 Pt 1):661-72.Human factors and cardiac surgery: a multicenter study.de Leval MR(1), Carthey J, Wright DJ, Farewell VT, Reason JT.
Amir A. Ghaferi, M.D., John D. Birkmeyer, M.D., and Justin B. Dimick, H. N Engl J Med 2009; 361:1368-1375October 1, 2009
![Page 57: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/57.jpg)
Safety I & Safety II
![Page 58: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/58.jpg)
Safety II
“Safety is the ability to succeed under varying conditions”
Eric Holnagel
![Page 59: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/59.jpg)
![Page 60: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/60.jpg)
Learning from Excellence @adrianplunkett
![Page 61: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/61.jpg)
Learning from Excellence Start-up Guide http://learningfromexcellence.com/resources/
![Page 62: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/62.jpg)
Safety Solutions Engineering & System Behaviours
Leadership, Risk Management &
Organisational Culture
Design, redesign & improvement
- Technology
- Standardisation
- Bundles
- Checklists
- Forcing functions
- Redundancies
Understand the work
Human factors
- Communication
- Physical limitations
- Cognitive
High Reliability Organising
- Team Attitude & Team Work
- Practice & Simulation
- Situation awareness
- Include patients & families
![Page 63: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/63.jpg)
Becoming safe
![Page 64: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/64.jpg)
Safety is a Choice
Will
Ideas
Execution
![Page 65: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/65.jpg)
![Page 66: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/66.jpg)
Berwick Report
![Page 67: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/67.jpg)
Importance of Culture
‘In the end, culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime.’
Berwick Review, 2013, (p.11)1
![Page 68: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/68.jpg)
A Safe Culture
Learning culture
Just culture Reporting
culture
![Page 69: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/69.jpg)
Manchester Patient Safety Framework (MaPSaF)
![Page 70: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/70.jpg)
Safety Culture Maturity
Pathological
Reactive
Calculative
Proactive
Generative
![Page 71: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/71.jpg)
The Origins of Patient Safety
Fitzsimons J. Vaughan D. Top 10 interventions in Paediatric Patient Safety. Curr Treat Options Peds (2015) 1:275–285
![Page 72: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/72.jpg)
Measuring Safety First Do: Know Harm!
• Incident reporting
- Healthcare staff
- Parents and families (different from complaints)
• Serious Incident review & Root cause analysis
• Trigger Tools
• HSMR
![Page 73: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/73.jpg)
Trigger Tools
![Page 74: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/74.jpg)
Trigger Tools
![Page 75: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/75.jpg)
A framework for measuring and monitoring safety Charles Vincent et al Health Foundation 2014
![Page 76: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/76.jpg)
A framework for measuring and monitoring safety Charles Vincent, Health Foundation 2014
![Page 77: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/77.jpg)
A framework for measuring and monitoring safety Charles Vincent Health Foundation 2014
![Page 78: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/78.jpg)
State of the art: Patient Safety 2013
Shekelle PG et al. Annals of Internal Medicine. 2013 Mar;158(5_Part_2):365-368.
![Page 79: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/79.jpg)
Irish Patient Safety Resources www.hse.ie/eng/about/Who/qualityandpatientsafety/
Quality & Safety Walkabouts Safety Pause
![Page 80: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/80.jpg)
Irish Patient Safety Resources NCEC Guidelines for Patient Safety
![Page 81: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/81.jpg)
A Challenge!
“When as kids we came to an orchard wall that seemed too high to climb, we took off our caps and tossed them over the wall, and then we had no choice but to follow them. I had tossed my cap over the wall of life, and I knew I must follow it, wherever it had fallen.”
An Only Child
Frank O'Connor
![Page 82: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/82.jpg)
Resources
Ireland
• HSE Quality Improvement Division
• National Committee for Clinical Effectiveness
UK & International
• Health foundation www.health.org.uk
• Berwick Review into Patient Safety
• Institute for Healthcare Improvement www.ihi.org
• Clinical Human Factors Group www.chfg.org
• Agency for Healthcare Research & Quality www.ahrq.gov
• Lucian Leape Institute
![Page 83: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/83.jpg)
Innovation in Patient Safety https://hbr.org/2016/08/the-next-wave-of-hospital-innovation-to-make-patients-safer
![Page 84: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/84.jpg)
Knowing your system
![Page 85: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/85.jpg)
PEWS – Listening to You Children & families as part of the safety system
![Page 86: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/86.jpg)
Creating a Culture of Excellence
![Page 87: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/87.jpg)
Common Cognitive Errors
![Page 88: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/88.jpg)
Improving Diagnosis in Health Care
National Academies of Sciences, Engineering, and Medicine. 2015.
Improving diagnosis in health care. Washington, DC: The National
Academies Press.
“Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions”
![Page 89: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/89.jpg)
National Academies of Sciences, Engineering, and Medicine. 2015.
Improving diagnosis in health care. Washington, DC: The National
Academies Press.
![Page 90: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/90.jpg)
• Follow us on Twitter @QITalktime
• Watch recorded webinars at your convenience on HSEQID QITalktime page
Keep up to date with QITalktime
![Page 91: The Science of Patient Safety – Dr John Fitzsimons · 2019-04-09 · Dr John Fitzsimons • Dr John Fitzsimons is a Consultant Paediatrician at Our Lady of Lourdes Hospital, Drogheda](https://reader034.vdocument.in/reader034/viewer/2022042115/5e92bb232a661f1f537eb62a/html5/thumbnails/91.jpg)
• Thank you from all the team @QITalktime
Thank you and stay tuned......