Patient Safety: What Should We Be Trying To Communicate?

Patient Safety
What should we be trying to communicate?

Making Tomorrows Doctors Safer
January 2011
Charles Vincent
Professor of Clinical Safety Research
Department of Surgical Oncology & Technology
Imperial College London
www.cpssq.org
Overview
Understanding patient safety

What have we learned so far?
Teams create safety
So what should we try to communicate in
education and training?
Imperial Academic Health Sciences Centre
Defining patient safety
`The avoidance, prevention and amelioration of

adverse outcomes or injuries stemming from the
process of healthcare
Negative or positive
Reactive or proactive
An Aspiration & Ambition
One of a number of objectives
The heart of quality
Consequences of serious adverse events

for patients & families
Death of neonates, children, adults

Loss of womb in young women
Untreated cancer, mastectomy
Blindness
Disability and handicap, children and adults
Chronic pain, scarring, incontinence
Profound effects on all aspects of their lives
Vincent, Young & Phillips, 1994
Impact of mistakes
Ì was really shaken. My whole feeling of self worth

and ability was basically profoundly shaken
Ì was appalled and devastated that I had done this to
somebody
`My great fear was that I had missed something, then
there was a sense of panic
Ìt was hard to concentrate on anything else because I
was so worried (Christensen, 1992)
Patient Safety in the UK
UK Department of Health, 2000
Epidemiology of harm
Study
Date of
admissions
Number of hospital
admissions
Adverse event rate

(% admissions)
California Insurance
Study
1974
20864
4.65 *
Harvard Medical
Practice Study
1984
30195
3.7
Utah-Colorado
1992
14052
2.9
Australian
1992
14179
16.6
United Kingdom
1999
1014
10.8
Denmark
1998
1097
9.0
New Zealand
1998
6579
11.2
France **
2002
778
14.5
Canada
2000
3745
7.5
The unreliability of healthcare
Undre et al, 2006
Understanding why things go wrong
The safety paradox
Healthcare staff are:
Highly trained & motivated
Committed to their patients
Use sophisticated technology
Errors are common and patients are frequently

harmed
Understanding why things go wrong
Chain of events
Complexity and contributory factors
The importance of cumulative minor errors
and deviations
Tackling safety on many levels
Contributory factors: 7 levels of safety
Patient
Task
Individual staff
Team
Working conditions
Organisational
Government and regulatory
Vincent, Adams, Stanhope 1998
Teams create safety
I Reliability of ward care
(1) How well do you understand the goals of care

for this patient today?
(2) How well do you understand what work needs
to be accomplished to get this patient to the next
level of care?
Less than 10% of nurses or doctors could answer
these questions
Pronovost et al, 2003
The Impact of Daily Goals
Structured and
organised care for each
patient
Reliability reducing
the gap between what
should be happening
and what is actually
happening
Reduced length of stay
from 2.5 to 1.3 days
Pronovost, 2003
II Patient handover
M
o
n
i
t
o
r
V
e
n
t
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P
ow
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AaeA
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i
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R
egirar Pum
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C
C
C
R
e
g
/N
urs
rsain P
D
u
m
p
N
ursN
eurse U
rine S
urgeon
Multiple specialists
Complex tasks
Complex interfaces
Time pressure
Need for accuracy
Catchpole et al, 2007
Process Organisation
Pit Stop
Task sequence
A rhythm and order to events
Task allocation
Team members have defined tasks
Leadership
Who is in charge
Discipline and composure
Explicit communication strategies to
ensure calm and organised atmosphere
Handover
Stages in process clearly defined
Ventilation: Anaesthetists
Monitoring: ODA
Drains: Nurses
Anaesthetist has overall responsibility

Defined moment for transfer to intensivist
Comms limited during equipment phase
Order for briefing (Anes; Surg; Discuss;Plan)
No interruptions
Catchpole et al, 2007
Performance improvements with new

handover protocol
Observation of 23 pre- and 27 post- handovers, balanced for operative risk
Number of Errors
Information Omissions
Duration (mins)
III Care bundles & organisational change
Decreasing catheter related bloodstream

infections
Hand washing
Full barrier precautions
during the insertion of
central venous catheters
Cleaning the skin with
chlorhexidine
Avoiding the femoral site
if possible
Removing unnecessary
catheters
Median rate of infection

per 1000 catheter days
decreased from 2.7 at
baseline to 0 at 3 months
Mean rate at baseline
decreased from 7.7 to 1.4
at 16-18 months follow up
Care bundles & organisational change
A focus on systems
Local ownership and engagement
Encouraging local adaptation of the intervention
Creating a collaborative culture
Time and resources
Pronovost et al, 2008
So what should we try to communicate?
Becoming aware
Communication in Emergency Care

Tracking the process Ì just could not believe
we were doing all this
Observing the handover `Staggering, jaw
dropping
Putting on my `second hat (Krishna Moorthy)
The essentials of patient safety
The human tragedies

Scale of error and harm
The safety paradox
Reflecting on ones own environment
The informal nature of many healthcare processes
The many levels of influence and intervention
The potential for simple changes
That they can make a difference
Safety in clinical practice I
I do not undertake any procedure unless I am sure I am

competent in performing it or have adequate supervision.
Senior clinicians say they want juniors to err on the side of
safety yet many younger clinicians fear seeming weak. I
make a point to reminding myself day after day that I want
to be safe first and brave afterwards.
Spending longer with patients explaining and discussing
the risks and benefits of treatment
Being obsessive about hand washing. I am now very aware
of why we are asked to do this and so less irritated about
the time it takes
Having enough humility to recognize when you are
stepping beyond your depth and willingness to ask for help
(Jacklin, Undre, Olsen)
Safety in clinical practice II
Being more vigilant in terms of errors that occur in day to

day practice which I may have missed in the past.
Being willing to address loose ends rather than say this is
not part of my problem.
Involving the patient in their care. For example always
asking the patient which side they thought they were
having the operation.
Being more explicit about my instructions, discussing
everything I think or intend to do to with the patient
At handover always summarising the situation, outlining
the plan and being absolutely clear about what to monitor
and at what point I want to be called
(Jacklin, Undre, Olsen)
Further Information
Clinical Safety Research Unit

www.csru.org.uk
Centre for Patient Safety & Service Quality
www.cpssq.org

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Patient Safety

What should we be trying to communicate?

Understanding patient safety

Imperial Academic Health Sciences Centre

Defining patient safety

`The avoidance, prevention and amelioration of

Consequences of serious adverse events

Death of neonates, children, adults

Vincent, Young & Phillips, 1994

`I was really shaken. My whole feeling of self worth

Patient Safety in the UK

UK Department of Health, 2000

Adverse event rate

The unreliability of healthcare

Undre et al, 2006

Understanding why things go wrong

The safety paradox

Healthcare staff are:

Highly trained & motivated

Committed to their patients

Use sophisticated technology

Errors are common and patients are frequently

Understanding why things go wrong

Contributory factors: 7 levels of safety

Teams create safety

I Reliability of ward care

(1) How well do you understand the goals of care

Pronovost et al, 2003

The Impact of Daily Goals

Catchpole et al, 2007

Anaesthetist has overall responsibility

Catchpole et al, 2007

Performance improvements with new

III Care bundles & organisational change

Decreasing catheter related bloodstream

Median rate of infection

Care bundles & organisational change

Pronovost et al, 2008

So what should we try to communicate?

Communication in Emergency Care

The essentials of patient safety

The human tragedies

Safety in clinical practice I

I do not undertake any procedure unless I am sure I am

Safety in clinical practice II

Being more vigilant in terms of errors that occur in day to

Clinical Safety Research Unit

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