1. Senior Lecturer Primary Health Care and General practice
"Patient Safety Investigation" or "Disciplinary Process to Find Fault " how do we decide?
Dr Ben Gray GP
Convener Professional Skills Attitudes and Ethics University of Otago Wellington
Senior Lecturer Primary Health Care and General practice

2. My Credentials
GP for underserved population
Expert Witness before Health Practitioners Disciplinary Tribunal
One patient subject of Severity Access “1” patient safety report
Two patients subject of complaint investigation by HDC
Many clinical episodes that if complaints had been lodged I may have been disciplined.

3. Terminology
Adverse Event
Adverse Outcome
Sentinel Event
Medical Error
Patient Safety Incident
Complaint

4. Patient Safety Incidents
Sentinel events
Adverse outcomes
Preventable adverse events
Adverse events
Medical errors
Complaints =
Juliet Broadmore 2006

5. James Reason Intrathecal Vincristine Fatality
Patient injected vincristine intrathecally and died. 14 previously documented episodes. Operating procedure developed to try to avoid a repeat.
Brian Toft. External Inquiry into the adverse incident that occurred at Queen’s Medical Centre, Nottingham, 4th January In: United Kingdom Department of Health, editor. London 2001.
Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline p. ii28-33.

6. Person approach to Error
The longstanding and widespread tradition of the person approach focuses on the unsafe acts—errors and procedural violations—of people at the sharp end: nurses, physicians, surgeons, anaesthetists, pharmacists, and the like. It views these unsafe acts as arising primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness. The associated counter measures are directed mainly at reducing unwanted variability in human behaviour. These methods include poster campaigns that appeal to people's sense of fear, writing another procedure (or adding to existing ones), disciplinary measures, threat of litigation, retraining, naming, blaming, and shaming. Followers of this approach tend to treat errors as moral issues, assuming that bad things happen to bad people—what psychologists have called the just world hypothesis.

7. System approach to Error
The basic premise in the system approach is that humans are fallible and errors are to be expected, even in the best organisations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in “upstream” systemic factors. These include recurrent error traps in the workplace and the organisational processes that give rise to them. Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work. A central idea is that of system defences. All hazardous technologies possess barriers and safeguards. When an adverse event occurs, the important issue is not who blundered, but how and why the defences failed.

8. The Swiss cheese model of accident causation
The Swiss cheese model of accident causation. The slices of cheese represent successive layers of defences, barriers, and safeguards.
Reason, J Qual Saf Health Care 2004;13:ii28-ii33
Copyright ©2004 BMJ Publishing Group Ltd.

9. Qualifications
Not about egregious behaviour
“Incidents that involve a criminal act, or substance abuse by the health practitioner, a deliberate unsafe act, or a deliberate consumer harm”
Public Hospital Incidents

10. Differences in two investigation systems.
Health and Disability Commisstion
Health Quality and Safety Commission
New (2-3yrs)
System set up in public hospitals
Patient Safety incident; could be complaint, bad outcome, staff report
Triaged and coded
All Severity Assessment Criteria 1-2 investigated
Investigation done by clinical team leader and patient safety officer.
Well established
Triggered by complaint
Complaints triaged ++++
Formal investigation triggered.
Investigation by officer at HDC
Involve named clinical advisors
Decision made by Commissioner (deputy)

11. Differences between HDC and HQSC Investigation Processes (1) What happened?
Health Quality and Safety
Health and Disability
The “truth” (like seeing the video) -
Face to Face reports +
Written reports
Freely given recall without threat of repercussion
Legally edited recall
Written documents (patient notes)
Soon after (1…….5) much later
1-3
3-5

12. Differences between HDC and HQSC Investigation Processes (2) The Investigator
Health and Disability
Health Quality Safety
Investigator at a distance
Investigating officer with advice.
Dependent on advice about the system
Investigator on site
Senior Clinician
Good understanding of system within which incident occurred

13. Differences between HDC and HQSC Investigation Processes(3) Focus
Health and Disability
Health Quality Safety
Response to complaint.
Dual role, to determine If there was a breech and quality improvement
Response to patient safety incident.
Single role: quality improvement

14. Differences between HDC and HQSC Investigation Processes(4) Report and Recommendations
Health and Disability
Health Quality Safety
Report delayed often 2 years
External recommendations ? Less likely implementation
Report within months
Internal recommendations ? more likely implementation

15. Differences between HDC and HQSC Investigation Processes(4) Limitations
Health and Disability
Health Quality Safety
Few serious events complained of.
Conflict between goals, leads to limiting quality of information
Findings usually limited to the individuals and institution rarely outside of institution.
Cost/Resource Use
Dependent on trustworthy implementation of HQSC guidelines
Assurance of “no retribution” limits response to finding egregious behaviour.
One purpose is to look for wider systems problems.
Cost/resource use