Engaging clinicians in patient safety

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Engaging clinicians in patient safety

• Miss Sisse Olsen MRCS PhD
• Clinical Safety Research Unit
• Imperial College

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Patient harm does happen
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• UK study of Adverse Event
• Rate of 11
• 50 preventable
• Annual cost to NHS 2 billion pounds
• in extra bed days

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Identifying errors

• Awareness in daily practice
• MM meetings
• Incident reporting
• National outcome data
• Local record review
• Root cause analysis

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Why are clinicians difficult to engage
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Or..
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Why do record review

• Involve clinicians in critically appraising care
  given and promote safety culture
• To provide a clear view of local problems
• Highlights minor events as indicators of areas of
  vulnerability before a major event occur
• Supplement to existing incident reporting systems
  and investigations of severe adverse events

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Local staff involvement

• Ward administrators
• Senior nurses
• Senior trainee doctors (SpR, Senior residents)
• Consultants/specialist
• Local management and risk management

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Review process
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Results of local real-time record review London 1
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Results of local real-time record review London 1

• Main problems in surgery
• Diagnosis
• Post discharge follow-up and investigation
• Ongoing management
• Action New imaging and follow up slots provided

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Results of local real-time record review - Spain

• Preliminary results on 110 patients
• All patient had undergone surgery
• 9 AE and AE in 9/110 admissions (8)
• Main problem Infection and Technical problems
  during operations
• Action Change to hand hygiene procedures and
  attitude to risk of transmission
• Change in attitude and openness about safety
  issues and adverse events in the unit

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Results of local real-time record review - London
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• Adverse events
• Rate 12 of patients
• Critical incidents/Near miss
• Rate 18 of patients
• Main types of problems
• Problems with ongoing management of patients
• Diagnosis
• Medication
• Action
• Change to team structure with distribution of
  clear responsibility
• Change to ward round routines
• Change to preoperative assessments

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Advantages of local record review

• Clinician led data collection
• Ownership of data led to strong sense of
  responsibility for improvement
• Open discussions of problems based on data from
  multiple cases lessened stigma of failure
• Change program initiated and driven by clinicians

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How to make it happen

• Strong organisational support
• Identify local champions
• Build on existing activities SpR audit
• Ownership of process and data
• Start with what is possible

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Questions??

• Miss Sisse B Olsen
• s.olsen_at_imperial.ac.uk