Patient safety, clinical governance and risk management

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Patient safety, clinical governance and risk
management

• Stuart Emslie
• WHO consultant to KKM

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Stuart Emslie

• Former academic, Strathclyde University,
  Scotland, specialising in healthcare risk
  management
• Formerly Head of Controls Assurance for the
  National Health Service in England, Dept. of
  Health
• Currently independent healthcare consultant
  specialising in healthcare governance, risk
  management and patient safety
• World Health Organisation (WHO) consultant on
  clinical governance, risk management patient
  safety to Malaysian Ministry of Health
• Visiting Fellow in healthcare governance and risk
  management at Loughborough University, England
  developed and leads part-time MSc degree in
  healthcare governance
• Visiting Lecturer, clinical governance, Oxford
  University Medical School, England
• Visiting Lecturer, risk management clinical
  governance, Flinders University School of
  Medicine, Australia (China Singapore)
• Advisor on clinical governance to Health Service
  Executive, Ireland

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Objectives

• Understand clinical governance (including
  patient safety and risk management)
• Explore the Irish framework for integrated
  quality, safety and risk management as a means
  of achieving excellence in clinical governance
• Determine whether the Irish framework might be
  worthy of adoption by KKM for public hospitals in
  Malaysia and what modifications to the framework
  would be required.

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www.ministryofhealth.wordpress.com
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MYR 75 billion - - - gt100,000 employees
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• Medicine used to be simple, ineffective and
  relatively safe. Now it is complex, effective and
  potentially dangerous.
• Sir Cyril Chantler
• Former Dean
• Guys St Thomass
• Medical Dental School
• London

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Technology Development and Risk in Healthcare
Technology Development
Development
Risk Gap
Training
Time
c2001
c1980
c1950
Source Chris Quinn, Newcastle Hospitals NHS
Trust, England
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UK blunders by doctors kill 40,000 a
yearSunday Times, 19 Dec 1999
Medical error is the third most frequent cause
of death in Britain after cancer and heart
disease.kills four times more people than die
from all other types of accidents.
NB USA approx. 98,000/year Australia approx.
10,000/year
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Hospital condemned over deaths after 'appalling'
failures in careHealth secretary apologises over
damning report on Mid Staffordshire NHS trust

• Between 400 and 1,200 more people died than
  would have been expected at Mid Staffordshire NHS
  foundation trust over three years.
• Although it is not clear how many of these deaths
  could have been avoided, the Healthcare
  Commission said patients undoubtedly suffered as
  a result of lapses in the standard of care.

17 March 2009
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Mirror.co.uk NEWS
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Examples

• Aintree Hospital a tube that was helping the
  patient breathe dislodged, causing a fatal heart
  attack and in separate incident a chest drain
  being inserted to relieve pressure on the lungs
  pierced the heart with horrific consequences
• Death of a patient at York given the wrong
  medication
• A missed diagnosis of meningitis led to a childs
  death at East Kent Trust
• At the Royal Hampshire County Hospital 23
  patients died of C.diff
• Five babies on the neo-natal unit contracted MRSA
  at Winchester and Eastleigh
• A swab was left inside a patients abdomen after
  a caesarean last June at Queen Marys Sidcup NHS
  Trust
• At East Cheshire NHS Trust a patient had the
  wrong part of their body operated on
• etc.

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From www.healthcaregovernance.info
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Study Year No hospitals No case records Incidence AEs Incidence prev AEs Type of study
California 1975 24 20864 4.6 0.78 Insurance
NY State 1984 51 30121 3.8 0.95 Malpractice
Utah-Colorado 1992 28 14700 2.9 0.93 Compare NY
Australia (Vict./S.Aust) 1993 31 14179 16.6 8.4 Quality
U.K. (London) 1999 2 1014 10.8 5.2 Feasibility
Denmark 2000 17 1097 9.0 3.6 Pilot
N. Z. (Auckland) 2000 3 1326 10.7 4.3 Feasibility
Canada (Ottawa) 2002 20 3745 7.5 2.8 Quality
France (Aquitaine) 2002 7 778 14.5 4.0 Quality
8.9
3.4
Average
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Doctors v. Gun Owners

• Number of physicians in the US 700,000
• Accidental deaths caused by physicians/year
  98,000
• Accidental deaths/physician per year 0.14
• Number of gun owners in US 80,000,000
• Number of accidental gun deaths/year 1500
• Accidental deaths/gun owner .0000188
• ?Conclusion - Doctors are approximately 7500
  times more dangerous than gun owners!

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Why do doctors kill more people than
airline pilots? Airline pilots are required to
have time off to sleep, do everything in
duplicate and follow protocols. British Medical
Journal Vol 1 317 1998
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ROOT CAUSE ANALYSIS

• Improving the safety and quality of care by
  investigating and analysing incidents and issues
  to determine what went wrong, why, and the
  actions necessary to prevent recurrence

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www.jcaho.org
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Improvement strategies that punish
individual clinicians are misguided and do not
work. Fixing dysfunctional systems on the other
hand is the work that needs to be done Saul
Weingart, Harvard Executive, Session on Medical
Error and Patient Safety
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Bristol Royal Infirmary
In the period from 1991 to 1995 between 30 and
35 more children under 1 died after open-heart
surgery in the Bristol unit than might be
expected had the unit been typical of other PCS
units in England at the time.
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Clinical Governance

• A framework through which NHS organisations are
  accountable for continually improving the quality
  of their services and safeguarding high standards
  of care by creating an environment in which
  excellence in clinical care will flourish.

the framework through which organisations
influence the informal psychological and social
functioning of their staff.
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• "Clinical governance is the vital ingredient
  which will enable us to achieve a Health Service
  in which the quality of health care is paramount.
  The best definition that I have seen of clinical
  governance is simply that it means "corporate
  accountability for clinical performance".
  Clinical governance will not replace professional
  self regulation and individual clinical
  judgement, concepts that lie at the heart of
  health care in this country. But it will add an
  extra dimension that will provide the public with
  guarantees about standards of clinical care."
• Dr Sam Galbraith MPMinister for Health
  (Scotland)June 1998

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www.nao.gov.uk
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and clinical decision-making based on up-to-date
evidence of effectiveness
Including staff continuing professional developme
nt (CPD)
Source Based on National Audit Office
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Personal Work

• Read the Framework document, have a restful sleep
  and good breakfast, and come prepared tomorrow
  morning to do a self-assessment against the
  Framework document as a basis for moving forward
  over the next 2 days.