Quality Management

Thoughts on Adverse Events & Errors:

I attended the meeting at the RSM on Thursday 13.6.2002 and have jotted down a few points that caught my attention.

All the speakers were from the secondary care area or related mainly to it, which was sad in that a lot of problems arise with communications between the different parts of the health care system.

The current estimate of the cost of adverse events in hospitals is at present 2 Billion pounds per year. This together with the Governments recent reports “An organisation with a memory -2000” and ”Building a safer NHS for patients -2001” put the whole problem into its context.

A very useful talk was by Brian Capstick of Capsticks solicitor whose organisation is using their experience in avoiding problems and learning from mistakes to put in place mechanisms and structures in hospitals to do the same job.

They are piloting software to develop Guidelines and analyse adverse events though to be quite honest you could do most things with Word and Excel. The most important new development seems to be to have these things available electronically in the latest form. One of the cases described was intrathecal injection where there were 2 lots of Guidelines about.

Some points that Brian made were:-

Organisational process

• Train all staff ( log )
• Say when staff need supervision
• Allocated difficult problems to the most experienced
• Induction process
• Reduce staff turnover – agency staff are a liability

How to improve

• Write down the problems when things go wrong
• Audit the work
• Use external inspection

So far as education and training are concerned it was felt to be most important in reducing mistakes. An initial induction into a new job was a must and then appropriate training for the jobs required. A log-book was mention here as a way of seeing what was happening and being able to see when adverse events occurred whether the person concerned had be suitably trained.

There was quite a heated discussion about a “No Blame Culture” which in many situations did not work especially once the media and politicians where involved. Some concept such as a “Fair Culture” might be more appropriate. If one is to try and move away from the pin pointing of an individual and look into the whole system then the potential improvement is likely to be much greater but it becomes very difficult to know where to stop.

Sharing information between professionals was also highlighted and some discussion was had about the possibility of joint notes with a column to the right for major observations.

A dispiriting area was the frequency with which the same report kept being produced and finding that nothing had been done to move things on. This is an area that patients frequently are concerned about. They are keen that mistakes that happened to them should be acknowledged and systems put in place to prevent it happening again.

Keiran Walshe spoke about public enquiries and the reasons for them.

1. Establish facts
2. Learn from events
3. Cathartic experience
4. Accountability – blame
5. Political – progressing an agenda

There were conflicting interests of, Openness, Fairness, Rigor, Cost, Time.

Many people spoke of leadership and this was felt to be very important in that the whole organisation had to be ready to accept where there where problems and address them. Many mistakes happen because someone senior is not called but then one has to ask why this is. Maybe one does not call, the boss when he is asleep or doing his private work.

Hilary Scott – Deputy Health Service Ombudsman was a good speaker and particularly of interest in their analysis of problems and what they were allowed to deal with.

There were a couple of things that I got from Susan Williams (NPSA)

1. With airlines there is an inverse relationship between the number of near misses reported and the number of serious incidents. Thus an organisation that is reporting lots of problems is likely to find ways of avoiding them.

2. A public survey showed
- agree that human error is bound to occur – 91%
- think that quality is good or excellent – 77%
- support a no blame culture – 68%

Bullet points:-

• Real leadership is imperative – I got it wrong
• Standard quality measures – Guidelines, Audit, Procedures, log-books
• Application of new technology – intranets etc
• A fair culture – maybe No Blame is not achievable
• Team working and training
• Strong feedback drivers
• Long-term education and training which is recorded
• Short term induction and specific skill training
• Support for staff – psychological considerations
• Problem prevention in the planning stage.