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Patient safety, clinical governance and risk management

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Patient safety, clinical governance and risk management Stuart Emslie WHO consultant to KKM Hospital condemned over deaths after 'appalling' failures in care Health ... – PowerPoint PPT presentation

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Title: Patient safety, clinical governance and risk management


1
Patient safety, clinical governance and risk
management
  • Stuart Emslie
  • WHO consultant to KKM

2
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

3
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.

4
www.ministryofhealth.wordpress.com
5
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6
MYR 75 billion - - - gt100,000 employees
7
  • 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

8
Technology Development and Risk in Healthcare
Technology Development
Development
Risk Gap
Training
Time
c2001
c1980
c1950
Source Chris Quinn, Newcastle Hospitals NHS
Trust, England
9
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10
UK blunders by doctors kill 40,000 a
year Sunday 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
11
Hospital condemned over deaths after 'appalling'
failures in care Health 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
12
Mirror.co.uk NEWS
13
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.

14
From www.healthcaregovernance.info
15
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16
8.9
3.4
Average
17
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18
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!

19
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20
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21
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
22
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24
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

25
www.jcaho.org
26
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
27
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.
28
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.
29
  • "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 MP Minister for Health
    (Scotland) June 1998

30
www.nao.gov.uk
31
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
32
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35
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.
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