- 1 First slideshow
- 2 Second slideshow: Medical errors
- 2.1 $$ cost
- 2.2 ￼Warren Anderson
- 2.3 5 moments for hand washing
- 2.4 Professionalism in medical students
- 2.5 What is professionalism?
- 2.6 Definition of Professionalism
- 2.7 Doctors can’t be the only problem ...So what is wrong with the system?
- 2.8 Errors are common
- 2.9 ￼Examples of common types of errors
- 2.10 Why do errors occur?
- 2.11 Some examples
- 2.12 Reason’s Swiss Cheese Model
- 2.13 Holey cheese
- Mini Audit is useful for the portfolio
- Audit = quality control, following clinical practice guideline
- A continuous process of reviewing healthcare quality
- Against accepted / EB standards
- And implementing changes to meet the standard(s) as necessary
- Repeated to maintain high standards
- = a positive feedback loop
- Critical evaluation - why people don't do particular things (ask them why a certain thing isn't relevant to them)
- People modify guidelines to fit their practice
- Find out guidelines and who created them, how they work etc, how often people on the ward are taught about them
- Audit doesn't need ethics approval because it's part of normal practice
- Notes: ask for 10 successive patient notes from discharge from the hospital
- Ethics - you need to tell the people that you are watching them and what for
- Big Brother effect - people behave differently when they're being watched
- Audits are known to improve quality of care because we know audits improve behaviour
- "Is that what you'd normally do if you're busy? Or are there particularly parts of the guideline that are harder to do when you're busy?"
Clinical practice guidelines
- Created by royal colleges
- Reviewed and updated
- Introduced to staff and supported in practice
- You are likely to see some real problems as to why guidelines aren't fully adhered to:
- What are the underlying cases?
- How can this be improved on?
- If guidelines aren't followed, things can go wrong.
- Hand hygiene is the easy one.
- 'The killer bs' are why guidelines aren't followed
- Barriers = lack of time, energy, patients aren't coherent or awake etc
- Presentation to each other, upload it into eMed for portfolio, tutor marks it
Second slideshow: Medical errors
- Near miss: you start doing something wrong then realise you were doing it wrong and correct it (almost went bad) - detect as a gauge for when something bad could go wrong
- Nonpreventable adverse events: side effects of medications (can tell people about it though)
- Vast minority of adverse events are negligence
- Consider what good quality healthcare is for:
- Patients - communication
- Politicians - optimisation
- Training doctors - no errors
- Consultants - effective
- In Australia, up to 16% of hospital patients suffered an adverse event1
- 50,000 patients/year suffer permanent disability
- 18,000 patients/year die
- Iatrogenic injuries:
- 35% resulted from a failure of professionalism (not checking tests, being conscientious)
- Lack of care or attention, failure to request a test
- Acting on insufficient information, lapses etc
- 1% due to lack of knowledge
- Causes of iatrogenic:
- Drug, Dose, Time, Route
- 1999 - To err is human: building a safer health system:
- 44,000 to 98,000 people die in US hospitals each year due to medical error 2
- Medication errors (USA) result in 7,000+ deaths alone each year
- The financial cost is huge:
- USA $37.6 billion each year2
- In Australia the total health care budget was>$50 billion (2004) and adverse events cost us $2 billion = 4% of the health budget value!*
￼==Girl's death triggers NSW health inquiry==
- SMH Thursday, 24 January, 2008
- “The NSW government has been forced to call an independent inquiry into the state's public health system after a scathing assessment from a coroner investigating the death of a Sydney teenager.
- Vanessa Anderson, 16, died two days after being admitted to Royal North Shore Hospital (RNSH) with a skull fracture.
- She had been hit in the head with a golf ball during a morning tournament at Asquith in Sydney in November 2005.“
- Not the fault of one person - want to fix the system to eliminate the possibility of errors at all (human errors)
- http://news.sbs.com.au/worldnewsaustralia/girls_dea th_triggers_nsw_health_inquiry_538827
- Nov 22 2007 Royal North Shore Hospital Inquiry as noted by the Joint Select Committee hearing on 28 Nov 2007
- “Vanessa did not die from one person's mistake.
- She died because many people made mistakes at every level in that hospital.
- She died because the public hospital system was not safe.
- She died because budgets are prioritised over patient safety. Two years later, has anything changed? We suspect not.”
- Terms of reference for the NSW public health care system Special Commission of Inquiry:
- There's a big inquiry into this
5 moments for hand washing
- When you enter the room
- Before you touch a patient
- After you touch a patient
- When you do a procedure
- When you leave the room
- Best handwashers
- Nurses and midwives
- Worst handwashers
- Doctors and medical students
- Look at the creepy diagram for changing peoples' behaviour
- Safety culture = the next diagram. Trouble if one individual is trying to make the workplace safe
- Useful for audit
- Increased risk for professional misconduct:
- Male students
- Lower SES
- Failure of early pre-clinical examinations: affects conscientiousness. Less likely to be able to handle a stressful career
- In doctors:
- Males, surgeons and GPs had higher rates of complaints
- Males - don't talk as much, more paternalistic
- Surgeons - less communication time with patient is more chance of being sued; have a large ego
- GPs - time poor; have many different kinds of problems with no preparation; different types of patients with different types of needs
- Males, surgeons and GPs had higher rates of complaints
- Trend are present between medical student behaviour and medical practice
- Low predictive value
- Significant costs and resources dedicated already
- Most unprofessional doctors behaved well as students
- Most students with behavioural problems at university will go on to be good doctors
Professionalism in medical students
- Significant amount of discourse on policies, codes and opinion pieces
- Research data on professional behaviour in medical students was lacking
- What aspects of professionalism should be taught and assed?
What is professionalism?
- Professionalism is comprised of a set of values and behaviours that underpin the social contract between the public, medical profession and doctors
- Live up to unwritten rules based on doctors' status in society
- Major components of professionalism include empathy, honesty, patience, team-mindedness and intellectual curiosity
- Impatience would mean higher rate of errors because you're hurried
- Intellectual curiosity: look up something/check it up if you don't know something
Definition of Professionalism
- Subordinate own interests to interests of patients
- Demonstrates high ethical and moral standards
- Behaves according to an accepted social contract
- Demonstrates humanistic values such as integrity and honesty
- Shows responsibility and accountability
- Has a commitment to improve
- Copes with complexity and uncertainty
- Demonstrates reflective practice
- Blaming one person does nothing - just causes someone to lose lots of money
Doctors can’t be the only problem ...So what is wrong with the system?
- Health system prevents honesty and disclosure causing a vicious cycle of repeated errors
- Blame and shame culture
- Human error
- Individual at fault
- Major inquiries fail to deliver satisfaction to victims or change systems or prevent further errors
Errors are common
- On the wards, in Specialist Clinics, in General Practice, in the community..
- Discuss with 2 neighbours:
- What have you seen or heard? (No names or identifiers)
￼Examples of common types of errors
- Error in delay of diagnosis
- Wrong or outmoded test etc
- Error in operation or procedure
- Error in dose of drug etc
- Failure to provide a prophylactic treatment
- Failure in communication
Why do errors occur?
- Human mistakes
- System failures
- Active failures =“unsafe acts” (human)
- Latent conditions = “resident pathogens” (within the system)
- Active failure:
- e.g. inaccurate measurement of a dose of a drug
- e.g.ordering the incorrect test
- e.g.amputating the wrong limb (it still happens!)
- Latent condition:
- e.g.Similar labels on different drugs
- e.g.inadequate policy on how to deal with patients with same name
Reason’s Swiss Cheese Model
- Eventually all the holes line up and something goes wrong
- Cheese slices = defensive layers within the system, e.g. protecting against:
- unsafe acts
- management deficiencies
- psychological precursors to slips/mistakes.
- Holes = problems in the system: the active failures and latent conditions.