Re(think) Patient Safety Series – Blog 1

Over the last fifteen years I do believe that we have learned a lot about patient safety but I also I think we should press the pause button and before we press play or go forward for another fifteen years we should think about what we have learned and what we should do differently in the future.  I am constantly reading about patient safety, talking to others about patient safety, searching twitter and YouTube for talks and articles on patient safety – in the search of hope. Hope that I will find the solution to our shared problem.  Our shared problem is that we know that care should and could be safer.  I would like to share the three areas of research I have been focusing on.

1. Learning from incident reports and investigations
2. Embedding the just culture for safety
3. Closing the implementation gap between theory and practice

The first in this series covers learning; in particular learning from incident reports and investigations.

I was listening to a webinar only just recently by the Director for the Centre for Quality Improvement and Patient Safety at the University of Toronto, Kaveh Shojania.  A third of the way through his presentation he said: “Incident reporting is the single biggest waste of time in the last 15 years and it is the most mistranslated intervention from aviation”  Now this is not new for Kaveh, (you can google his name and find an interview with him and Bob Wachter) but he said it in such a way that I heard it differently. So I reflected.  The general view is that the more incident reports there are, the safer the organisation is, that high numbers of incidents reported equals a good safety culture. There has been a determined drive to increase incident reporting as a result.

However, incident reporting has become an end in itself.  As a risk manager I all too clearly remember being stuck at the top of a building with piles and piles of incident reports – the relentless flow of paper reports arriving on my desk and the desperate attempts to keep up with inputting them into the database. I remember trying to analyse them to see what they were telling me about the state of the organisation but all I kept doing was counting them and I never really felt I did any of them justice.  Incident reports were supposed to help us fix things. However, for every incident, small failures often go unnoticed and unreported.  So we focus on pie charts and trend data of what gets reported and the numbers continue to rise year on year with consistently the same types of incidents reported from consistently the same settings and people.  It’s relatively easy to increase the reporting rates if you really want to but after a while people notice that they keep reporting the same things and no one appears to be actually fixing anything.

Kaveh talked about the wrong types of events getting reported.  He said that incident reporting systems are used to capture problems better suited to other strategies.  He talked about falls as an example and said there is almost no point in reporting a fall, that they are a common enough problem at every hospital that you should stop doing incident reports.  That you wouldn’t want to do a root cause analysis about a fall every time it happens.  And there isn’t a single great solution, so it’s not clear what an organisation is supposed to do after analysing one or more individual falls. If our aim is to quantify and capture numbers of incidents then fine let’s report every fall but if our aim is to learn from incidents then he may have a point.  Are we ready to move on from individual incident reports of high frequency?

If we were learning then we would not keep repeating the same thing from happening time and time again:

• operating on the wrong leg
• administering the wrong dose of a drug
• giving a patient the drug they are allergic to

I recently put the term ‘ten times the dose’ into Google and numerous reports came up. One in particular was by a nurse called Kimberley who, just like me, worked in PICU although her story was 20 years later. As a result of a ‘ten times the dose incident’ one of the children in her care died. I read about Kimberley’s interview for the root cause analysis – she said the following:

I messed up, I’ve been giving calcium chloride for years, I was talking to someone while drawing it up, I miscalculated in my head, I will be more careful in the future

You can see she felt she was personally and solely culpable for this incident.  She also gave us clues as to why the incident happened; distraction, automaticity, calculating in her head.  I will be more careful in the future is not a recommendation for sustained change.  Kimberley was suspended from work and sadly she never got over this incident. A few months later she committed suicide as a result.  So why have we not fixed this?  Why is it possible to still make a ten times the dose error?

If we were learning then we would give the right treatment at the right time.  I was listening only the other day to Scott Morrish talk about his 3 year old son Sam who died as a result of sepsis. The investigation found that he died due to a delayed diagnosis and a delay in administering the prescribed antibiotics.  I sat there listening; I was expected to provide a response to his talk as part of a panel session that followed him and James Titcombe. Two dignified parents in the face of such personal trauma.  As I listened I reflected on Martin Bromiley, Jayne Zito, Chezelle Craig, Claire Bowen and many more, whose voices represent so many patients and loved ones who have died as a result of their treatment.  I reflected too on the many stories from nurses, doctors and others who had been affected by harmful events.  So many stories over the last fifteen years.  I was truly saddened and moved beyond words by this dignified man in front of me – but I was also hugely frustrated and angry.  It was unacceptable that Scott was there telling us his story.  It is unacceptable that these stories continue to be told.  It will be unacceptable that we don’t do something differently.  The thing is, our current approach to investigations is often filled with flaws:

• They are usually carried out weeks and months after the incident
• People don’t remember a lot of what happened, they forget what they did or what others did
• Outcome, hindsight and confirmative bias all play their part to skew the truth
• We make it really hard for the patients and the families involved who simply want answers.  We need to make it easier for them to get the right answers as soon as possible

In particular the outcome bias is strong – we judge the same incident differently depending upon the outcome.  The outcome effect occurs when the same behaviour produce[s] more ethical condemnation when it happen[s] to produce bad rather than good outcome, even if the outcome is determined by chance.  If a nurse makes an error that causes no harm we consider the nurse to be lucky.  If another nurse makes the same error resulting in injury to a patient we consider the nurse to be blameworthy and disciplinary action may follow –the more severe the outcome, the more blameworthy the person becomes.  This is a flawed system based upon the notion that we can totally control our outcomes.  Interestingly outcome bias has influenced our legal system..

–A drunk driver suffers far greater consequences for killing someone than merely damaging property, the drivers intent is the same, the outcome very different yet society has shaped the legal system around the severity of the crime

–What is worrying here is that the reckless individual who does not injure someone sometimes receives less punitive sanction than the merely erring individual who caused injury

In the brief window (usually within 24 hours) between incident and investigation lies one of the very few opportunities to learn about what actually happened.  Instead we investigate a long way in time from the actual incident and come up with a variety of recommendations for:

• A new protocol
• Training
• Reminders
• Suspensions and restrictions

Remember also the changes we put in place, however good or bad they are, erode over time – we are very good at focusing intensely on something for a short while but we all take our eyes off the ball and resort to our original habits and behaviours unless we make fundamental design changes to the system which makes it hard for people to revert to old habits.

What should we do differently?  What needs a re(think)?

For example, there are many alternatives or backups to incident reporting that could help: Safety huddles, changing the reports to high level data capture – so you only capture the headline of the incident – this would then lead to a triage process by someone who knows what an incident that needs following up looks like – and only that much small number would be interrogated for more data and only a smaller group yet would be investigated, case note review – or the use of trigger words or even clever automation or data mining software would also help but we are not there yet.