PACE Patient Safety

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PACE Patient Safety

• An Overview of Root Cause Analysis and Human
  Error
• by Chris Bolam - Risk Manager Airedale NHS Trust

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Agenda

• What is Patient Safety
• Human Error
• Types of Error
• What stops Error
• Root Cause Analysis

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Impact on Staff

• It has been estimated that 38 of doctors
  who are subject of a clinical negligence claim
  suffer clinical depression as a result of the
  processthere is damage to a doctors reputation,
  morale, self-esteem and professional confidence.
• CMO Making Amends DH 2003

I am so afraid of making another mistake. I want
to give it all up and work in Tesco where the
worst mistake I could possibly make will only be
to annoy somebody, not kill them. Anon registered
nurse
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What is a patient Safety Incident ?
What do you consider are Patient Safety Incidents
?
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A Patient Safety incident is.

• Any unintended or unexpected incident which
  could have, or did lead, to harm for one or more
  patients receiving NHS funded healthcare.
• 
  NPSA 2004

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So how do Patent Safety Incidents Happen?

• What are Errors ?
• What type of errors do we make?
• What errors have you made ?
• What errors have you seen made?
• Why do you think errors are made

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Exercise
Team up with your neighbour and share a personal
mistake. Reflect on how and why it happened.
You will not be expected to share your story
with the larger group.
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The Person Approach

• Human actions are perceived as under voluntary
  control
• Accidents are due to carelessness, negligence,
  incompetence, etc
• Therefore accidents are someones fault
• And blaming individuals is easy, legally
  convenient and emotionally satisfying!

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The System Approach

• Fallibility is part of the human condition
• You cant change the human condition
• But you can change the conditions in which humans
  work
• The important questions are - How and why
  did the failure occur? - What can we do to
  reduce the chance of a recurrenceRemediation
  not Blame

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What is an error?

• The failure of planned actions to achieve their
  intended outcome.
• A deviation between what was actually done and
  what should have been done.

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Error

• Error is a normal condition of human existence,
  not an abnormal event. Because of the innately
  human limitations of the mind and body, we are
  vulnerable to
• limitations in memory capacity
• limited ability to deal with multiple competing
  demands weakened mental abilities, including
  decision-making, by things such as fear and
  fatigue
• influence from the effect of group dynamics and
  culture
• In recognizing these vulnerabilities, we have the
  opportunity to design systems to counteract our
  basic human frailties.

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Two ways of not achievingyour goal

• The plan may be OK, but the actions dont go as
  planned. These are called slips and lapses.
• The actions may go as planned, but the plan is
  inadequate to achieve the desired goal. These are
  called mistakes.

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ERROR TYPES based on the work of Reason,
adapted by NPSA
Unsafe acts
Skill based errors Memory failures
Skill based errors Attentional failures
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What do you think we mean by slips ?
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Slips of action(attention failures)

• Strong habit intrusions
• Omissions following interruptions
• Premature exits

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Lapses (Strong habit intrusions)

• Make tea instead of coffee. You are a tea
  drinker, but guest asks for coffee.
• Drive to work on Saturday morning when you meant
  to go to elsewhere.
• Intend to stop off to buy groceries on the way
  home, but drive straight past.
• What examples in the work place can you think
  about

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Mistakes

• Knowledge based mistake a novel situation for
  which your training and experience have not
  prepared you
• e.g. Australian tourists car skidding on black
  ice
• Rule based mistake an individual encounters a
  relatively familiar problem, but applies the
  wrong pre-packaged solution
• e.g. Rule always stop at an amber light.
• Mis-application in adverse weather or traffic
  states

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Three types of rule-based mistake

• Misapply a good rule
• Apply a bad rule
• Fail to apply a good rule (violation)

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Types of Violation

• Routine involve regularly performed short-cuts
  between task-related points, which are accepted
  locally, and sometimes by management. They
  generally occur due to the system, procedure or
  task being poorly described or designed

Everyday example of a routine violation - Not
using your indicator when turning off a main
road into a side road in a familiar area.
Healthcare example of a routine violation -
Identities of long-term patients not checked
because everyone knows who they are.
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How violations differ from errors

• Errors are unintended. Violations are deliberate
  (the act not the occasional bad consequences).
• Errors arise from information problems.
  Violations are shaped mainly by attitudes,
  beliefs, group norms and safety culture.

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Types of Violation cont.
Reasoned Violations are occasional deliberate
deviations from protocol or procedure where the
violation is for good reason. It is important to
ensure staff are not unfairly disciplined for an
act that was reasoned and had good intent. Adams
(2002)
Everyday example of a reasoned violation A car
driver driving through a red light, because his
passenger is in the final stages of delivering
her child.
Healthcare example of a reasoned violation GP
attending a motor vehicle accident may not have
time to put on protective clothing against blood
products, and so just carries on and treats a
seriously ill patient.
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Why do people like to commit violations?
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Violation types

• Corner-cutting violations
• Thrill-seeking violations
• Violations to get job done

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Human Behaviour is Predictable !
Its an emergency honest!
Only this once
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Why do people not follow the rules?
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Why people violate good rules

• I can handle it.
• I can get way with it.
• I cant help it.
• Everyone does it.
• Its what they want.
• Theyll turn a blind eye.

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Bad procedures

• Violations are only half the problem.
• The other half (or more) arises from bad
  procedures.
• In the nuclear power industry, 67 of all human
  performance problems have been traced to bad
  (incorrect, absent or unworkable) procedures.

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Reasons for notfollowing procedures

• If followed to the letter, job wouldnt get done.
• People are not aware that procedure exists.
• People prefer to rely on own skills and
  experience.
• People assume they know what is in the procedure.

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How are Errors Prevented?

• How do we prevent Healthcare workers from making
  errors?

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I Tried my best boss!
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Why RCA?

• RCA is a structured investigation that aims to
  identify the true cause's) of a problem, and the
  actions necessary to eliminate it (Anderson and
  Fagerhaug 2000)
• In depth analysis of a small number of incidents
  will bring greater dividends than a cursory
  examination of a large number
• (Vincent and Adams 1999)

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TYPES OF BARRIER
Insulation on hot pipes Fences
Physical
Natural
Distance, time, placement
Checking the temperature of a bath
Human Action
Administrative Controls
Training Supervision Policies and procedures
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Barriers, Controls and Defences
Human Action Barriers

• Checking the drug dosage before administering

Administrative Barriers

• Protocols and procedures e.g.
• Implementation of a drug administration policy
• Supervision and training

Physical Barriers

• insulation on pipes
• lead apron for radiographer

Natural Barriers time, distance, placement

• isolation of MRSA patients (placement)

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Identifying the Root Cause
HOW it happened
WHY it happened
WHAT happened
Performance Problem
Human Behaviour
Influences, control failure
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There are more than 40 RCA Tools

• Hierarchical Task Analysis
• Failure Modes and Effects Analysis
• Fault Tree Analysis
• CRU/ALARM Protocol
• Event Trees
• Spider Diagrams
• Scatter Diagrams
• Etc
• RCA Simplified Tools and Techniques, Anderson
  Fagerhaug
• RCA in Heath CareTools and Techniques, JCAHO
• Six Steps to Root Cause Analysis, Dineen (2003)

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Any questions?
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