1. Learning from incidents Keith Reynolds Risk Manager South Warwickshire General Hospitals NHS Trust

2. Incident Unplanned event which resulted or had the potential to result in injury, loss or damage

3. Incident example In 1998 the patient attended A+E having been stung by a wasp. Anaphylactic shock resulted and she was admitted to hospital for 6 days. One particular symptom was a period of blindness. Drugs prescribed include IV adrenaline, piriton, maxalon, and cyclizine.

4. Allegations A 1mg dose of adrenaline was given in one shot IV leading to a non- haemorrhaging infarct in the brain causing ischaemia affectingeyesight and causing amnesia amongst other symptoms. Claimant no longer able to work.

5. Cost n This case estimated at £480,000 n Total cases involving the Trust £10 million n Total cases settled last year in the NHS £250 million

6. Incident Investigation “Rather than being the main instigators of an accident, operators tend to be the inheritors of latent failures created at the blunt end. Their part is usually that of adding the final garnish to a brew which has been long in the cooking.” Reason: Human Reliability (1988)

7. Clinical care The environment of care Financial resources CLINICAL GOVERNANCE ORGANISATIONAL CONTROLS FINANCIAL CONTROLS Organisational Assurances (Annual Report) Clinical Assurances (Clinical Governance Report/Annual Report) Financial Assurances (Annual Accounts) Risk management and corporate governance

8. National Health Service initiatives n AS/NZS 4360:1999, Risk Management n Clinical governance n Controls assurance n Clinical Negligence Scheme for Trusts –risk pool –risk management standards with discounts

9. CLINICAL NEGLIGENCE SCHEME FOR TRUSTS - RISK STANDARDS n Clinical RM strategy n Defined Board responsibility n Clinical RM n Incident reporting system n Rapid follow-up of major incidents n Complaints management n Patient information on risks and benefits n Standards for medical record keeping n Induction arrangements for clinical staff n Clinical risk management system n Clinical care - guidelines, accountability etc n Maternity care standards for high risk pregnancy

10. RM STANDARDS (cont.) n Standards for medical record keeping n Induction n Clinical risk management system n Clinical care - guidelines, accountability etc n Maternity care

11. Controls Assurance standards n Risk mgt. system n Buildings, land,plant and non-medical equipment n Catering and food hygiene n Contracts & control of contractors n Emergency preparedness n Environmental management n Fire safety n Health and safety mgt. n Human resources n Infection control n IM&T n Medical devices mgt. n Medicines management n Professional and product liability n Records management n Security n Transport n Waste management n Decontamination

13. Everyone makes mistakes…..

14. Claims against the NHS Source: NHS Litigation Authority

15. Obstetric claims against the NHS

16. Even locally…….

17. Even locally…...

18. At every level……..

19. Why did it happen…...

20. Costs of clinical incidents Source: HSE (1997)

21. Typical total costs of a claim n Lacerations, minor scars---------£0-10k n Missed/delayed fractures--------£10-25k n Surgery to remove surg. mat.---£25-50k n Damaged organs, footdrop-----£50-100k n Fail sterilisation = live birth----£100k-1.13m n Paraplegia, blindness-----------£250-500k n Quadriplegia, brain damage--£500k-4.5m n Death---------------------------------£10-250k

22. Adverse incidents n Adverse incidents occur in 10% of hospital admissions n 37% of these result in disability n 8% result in death Source: Vincent, Neale and Woloshynowych BMJ 2001;322:517-519 ( 3 March )

23. Comparative SWGH figures using UCL study n 38,000 in-patient episodes pa (including Day Case) of which: –3800 inpatient adverse incidents –950 moderate or permanent impairment –304 deaths

24. Incident investigation findings n Under-reporting of incidents n Records –indecipherable –undated/not timed –no author –non-existent –no reason for treatment/test

25. Causes of incidents (NHSLA) n Failure to monitor, observe, or act n Delay in diagnosis n Incorrect risk assessment (for example, of suicide or self harm) n Inadequate handover n Failure to note faulty equipment n Failure to carry out preoperative checks

26. Causes of incidents n Not following an agreed protocol (without clinical justification) n Not seeking help when necessary n Failure to supervise adequately a junior member of staff n Incorrect protocol applied n Treatment given to incorrect body site n Wrong treatment given

27. Incidents The conjunction of… Reason, Human Reliability (1989)

28. Incident Investigation n Proximate causes n Sub-proximate causes n Root causes Root causes reveal areas which if changed reap the greatest benefit.

29. Incident example 68 year old female patient brought to A/E by ambulance with non-descript chest pain. Admitted to a medical ward and treated for thrombosis. Heparin written up for 24 hour period. Delayed KCCT test showed hypersensitivity to heparin. Blood not clotting. Patient had lung haemorrhage, subsequently arrested and died.

30. Proximate causes n Differential diagnosis n Patient weakened by morphine n Lung haemorrhage n Sensitivity to heparin n Sensitivity not detected n Prolonged use of heparin n No protamin administered

31. Sub-Proximate Causes n KCCT test not carried out in adequate time n Protocol for heparin administration not followed n Conflicting advice in use of Protamin

32. Root Causes n Procedure for receiving Telephoned lab results LTA n Lack of advanced diagnostic services n Inadequate Portering staff at the weekend n Procedure for urgent sample test LTA n Training, supervision and information for Junior Doctors LTA n Protocol for Protamin not communicated

33. Incident Investigation “Any accident is more tragic if human experience is none the richer for it.” A.D. Craven: Safety and Accident Prevention in Chemical Operations

34. Recommendations n Review clinical incidents n Make accurate, timely, identifiable, legible records n Review the patient when making potentially serious interventions n Act within level of competence n Keep up to date