In the previous commentary in this series about enhancing the value of investigations, I discussed the findings of an investigation involving missed/delayed diagnosis of acute leukemia. The original investigation had focused only on assigning blame, thus missing opportunities for learning. A deeper-dive investigation identified many actionable opportunities for improvements: (more…)
The core purpose of incident reporting is to learn from what happened in order to make improvements to future healthcare processes and systems and protect patients from harm.
However, research1,2 shows that as few as 7% of all patient safety incidents are reported. The barriers to incident reporting have been well researched and included many factors. Experience at Datix3 points towards the following themes:
- The forms are too complicated;
- Reporters do not receive feedback and cannot see that anything has changed as a result of their report;
- Fear of punishment or otherwise getting into trouble for reporting an incident or being labelled as a troublemaker.
When we try to dissect through the various confounding factors that contribute to delays and errors in diagnosis, it is important to understand that only by delving deeply can one realize opportunities for improvements. In the case of human errors, or what I prefer to call human mistakes, there are often multiple contributing factors and thus many opportunities for improvements1. When investigations fail to delve deeply to identify contributing factors, then processes do not improve, professionals and institutions do not learn from past mistakes and patients may continue to suffer. (more…)
In recent years, there has been an increasing recognition that the way in which the NHS investigates and learns from instances of avoidable harm and death is extremely variable and often poor. This is an issue that has been identified time and time again in major national inquiries, from Sir Ian Kennedy’s report into children’s cardiac surgery at Bristol in 20012, the Mid Staffordshire report in 20132, the Morecambe Bay report in March 20153 and more recently, the Mazars report4, which looked at the deaths of people with learning disabilities who came into contact with the Southern Health trust between April 2011 and March 2015.
The Mazars report was commissioned following the tragic death of 18-year-old Connor Sparrowhawk5. Connor, who had a learning disability and epilepsy, died in 2013 while receiving care at an assessment and treatment centre run by Southern Health NHS Foundation Trust. The report identified serious failings in how the trust recorded and investigated deaths and highlighted that certain groups of patients, including people with a learning disability, were far less likely to have their deaths investigated by the trust.
Diagnostic errors are ipso facto delays in arriving at an accurate diagnosis, often resulting in delays in appropriate therapeutic interventions and possibly resulting in harm. The reasons for diagnostic delays and errors are complex and invoke numerous inefficiencies in communication and collaboration between professionals and professionals and patients. When one includes the necessity of ordering, performing, and interpreting ancillary investigations, the complexity of challenges in diagnosis become even more apparent as numerous opportunities for errors abound in these domains also. Perhaps most importantly, inefficiencies in cognitive reasoning abound, are pernicious, are often unrecognized, and are confounded by an array of human factors that may impair judgment6. (more…)
Try as we might – despite our greatest efforts and accomplishments – humans have yet to create the perfect technology, one which subsists independently of human support and influence. We have developed great advances in medicine, tremendous engineering feats, and have achieved the power to imbue machines with pseudo-intelligence and the ability to calculate, reason, solve problems, and perform complex tasks on our behalf. And yet, we have failed to create a system in which we are nonessential. Regardless of advances in nanorobotics, wearable technologies, or anti-bacterial lighting for our operating rooms, humans remain ever present—the greatest variable in the healthcare industry. (more…)
The environment in which healthcare services are provided is complex. This is confounded by numerous variables that impair the noble goals of achieving higher reliability and improving patient and staff safety. The complexity in healthcare is based on multiple structures and processes, all of which must align to achieve ideal outcomes. But that simple model does not explain the complexity completely, as one must also consider the necessity and frequency of interactions between clinical and support staff and between staff and patients. All these interactions are affected by a bewildering array of factors that affect human performance. For this reason, when investigations are undertaken into causality of patient safety incidents, the culture of an institution as established and sustained by leadership, for better or worse, plays a crucial role. (more…)
There is an urgent need in health care that must be confronted. The latest studies regarding the deaths related to health care reveal that about 250,000 people die in the USA every year due to engagement with the US healthcare industry2. This is not because of underlying illnesses, but rather as a result of system and process insufficiencies and human mistakes. Many orders of magnitude more are harmed, often seriously harmed, and some are permanently damaged. The numbers are daunting and define a public health crisis of enormous proportions. Even if one wishes to debate the validity of the numbers, even if one instead uses the figure of just under 50,000 noted in the IOM report of 19992, this is still a public health crisis of great magnitude and affects thousands of mothers, grandmothers, fathers, grandfathers, children, sons, daughters, friends and lovers, even enemies. How can this be and what can we do about it?
It is essential that we strive diligently to learn from investigations of safety incidents to identify the system and process errors and human mistakes that result in injuries and deaths. We must do so in a systematic fashion that leads to actionable improvements in the provision of healthcare services, and thus in patient safety. Sadly, more often than we would imagine, so-called “root cause” analyses are inadequate, sometimes focusing on individual performance in a “blame and shame” fashion instead of truly understanding the complexities of contributing factors that result in causality at the tip of the needle.
Clinicians rarely, if ever, intend to harm patients, and in my view, if an investigation points to an individual as the root cause, then that investigation has not delved deeply enough.
In cases of incident reporting, it’s easy to focus on mistakes and events that directly result in the harm or improper care of individuals. However, incidents often include factors such as minor injuries, falls, and refusals to take medications. While seemingly inconsequential to the overall well-being and health of an individual, these incidents can help reveal serious underlying factors and aid in the avoidance of future mistakes and failures.
It’s easy to take data for granted. For many of us, data seems to simply materialize for our benefit. The methods by which data is collected is invisible to nearly all, save the individuals responsible for its acquisition; and prior to the arrival of Big Data, this information was collected painstakingly over great lengths of time and often resulted in incomplete or false information.
Traditionally, data was – and, in part, largely still is – collected by means of paper forms. In the world of healthcare, these forms come from various sources, including physician offices, patient histories, X-ray scans, hospital records, and surveys performed via telephone, email, and door-to-door visits. To be integrated into any form of computerized system, this data has to then be entered manually by groups of individuals over weeks, months, and even years of meticulous work.
We live in an era of mobile technology. Everything we need to know, everything we want to purchase or browse or better understand is carried with us in our pockets. Whether bank account summaries, cinema listings, Facebook updates, or tips on how to turn that old, unwanted pair of jeans into a set of placemats, our phones and tablets carry with them every bit of information we deem pertinent to our daily lives. As we, as a culture, continue to delve deeper into the ever-encompassing world of mobile technology, so do the suppliers of our food and clothing and entertainment have to move along with us, adapting their approach to supplying products and services to match our demand for instant consumption.
It makes sense that the world of healthcare would inevitably evolve to meet these same needs. And now, with the advent of mobile apps – such as Red Cross’ First Aid, MyChart, and Doctor on Demand, patients are given the same access to their healthcare services that they have grown accustomed to in all other aspects of their lives.
Advancements made in the healthcare industry over the years have been truly crucial in how we value and regard medicine. Technologies have been developed to perform surgeries and procedures not thought possible prior to their creation. Revelations have been made in the treatment of diseases once believed to be incurable, such as Malaria, Tuberculosis, and Measles, all of which are now perfectly treatable through proper care and medicine. It has not even been a hundred years since the advent of penicillin, which is unparalleled to any other discovery in modern medicine and responsible for saving untold lives since its introduction.
Last month, the Parliamentary and Health Service Ombudsman (PHSO) published a report relating to the tragic death of 3 year old Sam Morrish. Sam died in 2010 from sepsis. In 2014, the PHSO published a report that found Sam would have survived had he received appropriate care and treatment. However, whilst the 2014 report confirmed that Sam’s death was avoidable, it didn’t provide a satisfactory explanation as why it was that the local NHS failed to uncover what happened and therefore couldn’t ensure that necessary learning took place. At the request of Sam’s parents, the PHSO undertook a new investigation to look at why.
The report found that the local investigation process was not fit for purpose, was not sufficiency independent, inquisitive, open or transparent and that the people carrying out the investigation were not sufficiently trained. It’s a hard hitting, compelling document that builds on the now strong evidence base that tells us there is an urgent need for change in the way the NHS responds and learns from mistakes. Sam’s father, Scott Morrish said:
War is a terrible, horrible thing. As a former military physician, I have been to war and have seen the mayhem inflicted by the mechanics and methodologies of modern warfare, alarming and sobering stuff, indeed. It ain’t pretty and it sticks with you, forever!
Having said this, it remains a fact that many great advances in health care have resulted from the experiences of doctors and nurses serving in war zones and treating medical, surgical and psychological casualties of both military and civilian victims – resulting from the destruction and chaos of conflict.
It should not surprise any of us involved in healthcare professions that amidst all this havoc, individuals with great compassion and even greater insight and awareness often arise. The collective adrenaline of our medical culture, functioning under duress, often fosters brilliance and innovation. Good stuff and good people percolate upwards.
Here at the Datix HQ in Wimbledon, we’ve been learning about and discussing recent initiatives to report and learn from ‘excellence incidents’. There are a number of compelling reasons why reporting and learning from examples of good practice and excellence in healthcare are valuable. By sharing examples of outstanding care or improvement initiatives that have been shown to result in tangible benefits, this learning can be shared and emulated by others. The very act of recognising examples of excellence is also something that can greatly improve morale and help foster a supportive and positive culture.
There is also real value in looking in detail at specific incidents of excellence. A recent paper describes a process where such reports are given detailed consideration at an ‘IRIS’ (Improving Resilience, Inspiring Success) or reverse SIRI (Serious Incident Report Investigation). The paper describes the positive benefits derived from the process, including empowering front line staff to share ideas and innovation.
It is encouraging to learn that some organisations are starting to use Datix as a means of reporting ‘excellent incidents’ and we’ve even seen the term “GREATix” coined to describe such reports. We are currently working to see how we might be able to support such initiatives.
Leadership often is viewed as something emanating from the top and filtering downward. However, effective leadership is more about colleagues working together, buy-in and bottom-up implementation than anything else. For a leader to be effective, a culture of collegial buy-in must be present, and there must be reasons for followers to follow, to sustain a safety culture and to align their daily work efforts and patterns with clearly stated goals of the institution. Themes, goals and mission statements may emanate from the top, but their achievement depends on the efforts of subordinate levels of leadership and, ultimately, to those on the front-line.
In “closed” systems where members of staff are salaried employees, it may be easier to implement and sustain a culture of safety and to develop strategies to achieve institutional goals. In more “open” systems, where some doctors and nurses are employees and others are self-employed or working under contracts, especially agency staff, it may be more difficult for leadership to be effective. If leaders and front-line stakeholders are not aligned and working together to achieve the same outcomes, then safety and highest quality cannot be assured.
Leaders are responsible for establishing and sustaining the culture of an institution. They are accountable for monitoring the institution’s cultural rhythm. With strong leadership, that rhythm should vacillate only slightly, rather like the variations on a barometer as compared to those on a thermometer. The rhythm must be stable or else turbulence sets in, with associated disruptions and hazards. Safety degrades under such circumstances and patients and staff can be harmed.
A key strategy for success is for leaders to recognize vulnerabilities that may affect staff performance and to address them specifically. This is accomplished by sustaining a culture where just treatment, e.g., the Just Culture, is the norm. The Just Culture consists of two dimensions, related but also unique in character.
Considering the ubiquity of modern technology and computers, it seems an archaic notion that information such as patient records, healthcare policies, and guidelines would be stored by means of paper filing systems. However, it was not long ago that hospitals and other care facilities began implementing electronic systems for filing records in lieu of conventional and antiquated means of paper storage. (more…)