The Future of Patient Safety Seeing safety through the patient’s eyes Rene Amalberti & Charles Vincent Department of Experimental Psychology, Nuffield Department of Surgical Sciences University of Oxford

Overview u Our current view of patient safety u Broadening our view of harm: through the patient’s eyes u Starting from reality: 5 levels of care u Safety along the patient journey u Models of safety across settings u Implications and directions – Models of event analysis – The nature of safety interventions – The challenge of home care

The nature of harm u Incidents, accidents u Adverse events u Near misses, close calls etc. u Relatively circumscribed events – Hospital based (for the most part) – They have a history, but a short one – Observed by healthcare professionals

Incidents within a patient journey (Healthcare professionals’ view) Good care + incidents

Shekelle et al, 2013 u Targeted at events u Aim is to optimise reliability of basic procedures

Patient safety outside the hospital? u Little developed u Little traction? – Lack of interest? – Lack of infrastructure? – No incentives? – Wrong language and concepts?

I Broadening our view of harm Through the patient’s eyes

Patient harm happens in every healthcare setting: at home in convalescence, in an operating room under anaesthesia, at the lab getting blood drawn, in the hospital corridor lying alone on a stretcher …… Harm may result from wrong or missed diagnosis, scheduling delay, poor hygiene, mistaken identity, unnoticed symptoms, hostile behaviour, device malfunction, confusing instructions, insensitive language and hazardous surroundings. The trajectory of harm begins with the unexpected experience of harm arising from or associated with the provision of care, including acts of both commission and omission……... The patient may experience harm during the episode of care when the failure occurred, or later, after some time has passed. Harm as it is first endured may evolve, transform and spread (Canfield, 2013)

Harm through the patient’s eyes u Harm is conceived very broadly encompassing both serious disruption of treatment and distressing events. u Harm includes serious failures to provide appropriate treatment as well as harm that occurs over and above the treatment provided. u Harm is seen not in terms of incidents but as a trajectory within a person’s life.

A broader view of harm u Treatment specific harm u Harm due to over treatment u General harm from healthcare u Harm due to failure to provide appropriate treatment u Harm due to failed or inadequate diagnosis u Psychological harm and feeling unsafe u Harm due to neglect and dehumanisation

Explore dimensions of harm in each setting u Hospital acquired syndromes in care of the elderly – Dehydration – Malnutrition – Delirium – Depression – Pressure sores – Incontinence

II Starting from reality Five levels of care

Are our clinical systems and processes reliable? Measuring and testing reliability: the WISER study – – Clinical information availability at the point of decision making – Prescribing for hospital inpatients – Equipment in theatres – Equipment for inserting IV lines – Handover between wards

Past medical history Referral letter/other specialty letter Discharge summary Current medication Radiology/imaging results Diagnostic test results Procedure notes/anaesthetic record Electrocardiogram (ECG) report Blood results I’m looking for... 15% of patients with missing information across 3 hospitals

Equipment availability in operating theatres 19% of operations with one or more equipment problem

Quality ambition- Optimal care (almost never reached) 5 Care where harm undermines any benefits obtained Threat to health OPTIMAL BENEFIT INCREASED RISK OF HARM 1 The care envisaged by standards 3 Unreliable care/ poor quality The patient escapes harm 2 Compliance with standards- ordinary care with imperfections 4 Poor care with probable minor harm but overall benefits Area of Safety Area of Quality 5 levels of care ‘The illegal normal’

Quality ambition- Optimal care (almost never reached) 5. Care where harm undermines any benefits obtained Threat to health OPTIMAL BENEFIT INCREASED RISK OF HARM 1The care envisaged by standards 3. Unreliable care/ poor quality The patient escapes harm 2. compliance with standards- ordinary care with imperfections 4. Poor care with probable minor harm but overall benefits Interventions to optimise reliability Interventions to reduce harm The same thing?

III Safety along the patient journey Through the patient’s eyes

IV Managing safety in different contexts

No system beyond this point Civil Aviation Nuclear Industry Railways Chartered Flight Drilling Industry Chemical Industry (total) Fatal risk Anesthesiology ASA1 Innovative medicine (grafts, oncology …) ICU Trauma centers Very unsafeUltra safe Professional fishing Three Contrasted Safety models UnsafeSafe Himalaya mountaineering Combat A/C, war time Medical risk (total) Scheduled surgery Chronic care Radiotherapy, Biology Blood transfusion Finance Fire Fighting Food Industry Processing Industry u 2014

Embracing risk: ultra-resilient: u Taking risks is the essence of the profession u Cult of champions and heroes u Power to the experts – ‘give me the best tools to survive’ u Success analysis more important than accident analysis u Training. Experts talk to juniors, acquisition of expertise, understanding own limitations

Managing risk: high reliability model u Risk in not sought out but is inherent in the profession u Group intelligence and adaptation u Mutual protection team members. Suspicion of simple explanations u Training and safety focused on adaptability and flexibility of procedures

Avoiding risk: ultra safe u Risk is excluded as far as possible u Procedures & supervisory systems u Priority given to prevention u Strong regulatory control u Training focused on rigorous procedures and management of workload

Models of safety within healthcare u Embracing risk - Ultra resilient – Treatment of cancers with poor prognosis, military medicine, major trauma surgery u Managing risk – HRO model – Elective surgery, obstetrics u Ultra-safe – Laboratory medicine, blood products, radiotherapy

A model of safety for care in the home? ? ? ?

Rethinking patient safety

Redefining patient safety u Patient safety is the art of controlling risks of time to minimize harm (isolated or cumulative) in relation to benefits u The reduction of all incidents and minor harm is a secondary, though still desirable, objective. u Analysis should focus on understanding the ‘EVENT’ JOURNEY’: the sum of events positive and negative that make at end the care successful or tragic

Neither total compliance, nor zero harm u With this definition, patient safety is: – Not a ‘zero default’ approach with total elimination of any harm or incidents. – Not primarily a ‘process-driven’ approach aimed at total compliance with procedures, whatever the value of these procedures

The nature of safety interventions u Interventions need to be targeted at the real world not at the ideal world of regulations and standards u Optimal interventions will differ according to context u There is a limit to optimising reliability u Focus on risk control and mitigation as well as on error prevention and causation u Stronger focus on organisational interventions and building foundations of safety