1. Quality Education for a Healthier Scotland Enhanced SEA Chris Williams, Paul Bowie, Elaine McNaughton, Duncan McNab, John McKay & David Bruce

2. Quality Education for a Healthier Scotland Plan Analysis of SEA currently Why enhanced SEA? Human factors in SEA Why we blame Why error occurs Enhanced SEA process Results of pilot Example

3. Quality Education for a Healthier Scotland What is a Significant Healthcare Event? Significant Event Patient Safety Incident Adverse Event (Avoidable Harm) Near Miss (Potential Harm) Purely Reflective Other Quality of Care Issue ‘Positive’ Event

4. Quality Education for a Healthier Scotland Current expectations of SEA in GPST Reflecting and learning from interesting or complex cases or important safety events Identifying individual or practice training needs, and system weaknesses Facilitating the rapid implementation of change and improvement Contributing to the management of risk in the practice Enhancing the safety of patient care and local safety culture

5. Quality Education for a Healthier Scotland Investigations of Significant Events Poorly Conducted: Problems Incidents are highly selective (or non-engagement) Lack of a structured analytical framework (long standing issue) Many SEAs demonstrate a lack of ‘systems thinking’ Most clinicians attribute events to their own actions/inactions

6. Quality Education for a Healthier Scotland Investigations of Significant Events Poorly Conducted: Impacts Missed opportunities to learn & improve (personal, team & organisational) SEA becomes a tick-box exercise Perceived blame culture (fear, distrust, punitive action, litigation…) Negative feedback (interferes with ability to assimilate & process information beyond the ‘self’ level) Second-victim syndrome (impact on health & wellbeing of clinician: guilt, embarrassment, shame…)

7. Quality Education for a Healthier Scotland Why enhanced SEA? Overcome SEA deficiencies by introducing human factors systems principles Highlight and differentiate the interactions between the individual, their workplace and wider organisation. Individual Level: guide clinicians to reflect upon and contextualise their emotional reactions - achieve a state of psychological readiness to move on. may lessen –ve emotional reactions and apportioning of personal blame Team Level: a systems-centred analysis of the significant event. may lead to more meaningful and effective action plans for improvement.

8. Quality Education for a Healthier Scotland Human factors (Ergonomics) The interaction between humans, systems and the environment What it is NOT! – “This mistake was caused by human factors.”

9. Quality Education for a Healthier Scotland Human Factors (Ergonomics) in Healthcare In healthcare, it can be used to design all aspects of a work system to support human performance and safety, and prevent errors that may harm patients. Its goals are twofold: To support the cognitive and physical work of healthcare professionals, and To promote high quality, safe care for patients

10. Quality Education for a Healthier Scotland Awareness of human factors principles can help GPSTs to: Understand why errors are made and which ‘systems factors’ threaten the safety of patients Learn about and help to improve the safety culture of teams. Enhance teamwork and improve communication between healthcare staff Improve the design of “healthcare systems” and equipment Identify ‘what went wrong’ and predict ‘what could go wrong’

11. Quality Education for a Healthier Scotland Why do we blame? Convenient Prosecute Appease patients and public Psychological factors

12. Quality Education for a Healthier Scotland Blaming ‘Skills’ Hindsight Bias - this is the ‘I-knew-it-all-along’ effect The Illusion of Free Will - Most of us believe that we determine our own actions (most of the time) In other words, they ‘choose’ to make mistakes. Fundamental Attribution Bias - Our natural tendency is to attribute someone’s actions (especially undesirable actions) to their personality traits or characteristics while (unintentionally) ignoring contextual contributory factors that may have constrained their actions. Just World Hypothesis - We also assume that ‘bad’ things only happen to ‘bad’ people

13. Quality Education for a Healthier Scotland Human Error “Errors are the inevitable and usually acceptable price human beings have to pay for their remarkable ability to cope with very difficult informational tasks quickly and, more often than not, effectively”. Reason (1990)

14. Quality Education for a Healthier Scotland Human error Short-term memory capacity Gap between the level at which we expect to perform and reality Attention spans Our judgment will fail us Stress, fatigue and awareness levels can affect our judgments or perceptions

15. Quality Education for a Healthier Scotland Types of Error Active Errors: These are committed by frontline staff and tend to have direct patient consequences Latent Errors (or System Errors). Latent or system errors create the conditions, context and potential for Active Errors. They seldom have immediate consequences, but can potentially affect many more patients

16. Quality Education for a Healthier Scotland Human error – a systems approach “Error is not the monopoly of an unfortunate few” - when placed in similar circumstances, the majority of people will make similar mistakes.

17. Quality Education for a Healthier Scotland Enhanced SEA

18. Quality Education for a Healthier Scotland Enhanced SEA Part 1 – Address the personal and wider impact Part 2 – Adopt a human factors framework to analyse why event occurred Part 3 – Define the action plan

19. Quality Education for a Healthier Scotland Guide Tools Small Personal Booklet (with 4 card inserts) A3 size Desk Pad New written format for enhanced SEA reports

20. Quality Education for a Healthier Scotland 1. A small 12-page Personal Booklet (with 4 card inserts) to help individuals reflect on the potential emotional impacts of a significant event - and their own role in the event - by using human factors principles to gain a clearer understanding of all of the contributory factors involved.

21. Quality Education for a Healthier Scotland

23. 2. An A3 size Desk Pad for the care team, the sheets from which can be distributed to all those who attend a team meeting to analyse significant events. Each sheet contains instructions and prompts to guide the care team to take a systems-based approach to analysing the event in question and take notes on what was agreed – a small set of card prompts may also be used in conjunction.

24. Quality Education for a Healthier Scotland 3. A re-designed written report format for enhancedSEA – to prompt a systems based analysis.

25. Quality Education for a Healthier Scotland 1.About the Significant Event Please describe what happened (e.g. outline in sufficient chronological detail including how it happened, who it happened to and the location of the event). What was the impact or potential impact of the event? (e.g. on the patient/relatives, yourself, colleagues/staff – think in terms clinical, professional and organisational risks and implications).

26. Quality Education for a Healthier Scotland 2.Contributory Human & System Factors Please outline the different factors that contributed to WHY the event happened. People Factors (e.g. consider the people (ill patients/clients, staff interactions) who were directly and indirectly involved in the event and the communications between them and other factors). Activity Factors (e.g. complexity of the work task, lack of recognised care guidance or design of system or process). Environment Factors (e.g. consider practice culture, time and workload pressures, adequacy of equipment, available lighting, noise levels, distractions and interruptions. Please describe how these factors combined to make the event happen. (Think in-depth about the interactions between people, the activity you were undertaking, the practice and wider healthcare systems and environment that you work in). Did you identify these factors on your own or with input from other colleagues?

27. Quality Education for a Healthier Scotland Interaction of factors

28. Quality Education for a Healthier Scotland 3.Lessons Learned What lessons have been learned from the analysis of this event? (Think again about the complex interactions between People, Activity and Environment). What learning needs have been identified (at the individual, care team, and organisational levels, where appropriate)?

29. Quality Education for a Healthier Scotland 4.Action Plan for Improvement How have you minimised the chances of this event happening again? (Outline your Action Plan for Improvement and how you have implemented it together with the role and contribution of the wider care team, where appropriate. If you have yet to take action or judge that no action is necessary, please justify why this is the case). Who is responsible for ensuring that these actions are implemented and how will these be monitored and sustained in practice? (Outline your role and contributions and those of the wider care team, where appropriate).

30. Quality Education for a Healthier Scotland Statement and levels of agreement (%) Pre-Post- I have a good understanding of what a "significant event" is in the context of my healthcare role 8295* I fully understand how to undertake and lead a significant event analysis 6695* When a significant event is analysed, it feels like the person is being written up, not the problem 1913 Poor design of systems, rather than the actions of humans, is the biggest factor contributing to significant events in the workplace 3950* I have a good understanding of the discipline of “human factors” 3577* Highlighting significant events is a good way of identifying staff who need additional training 2434* I think undertaking SEA is a demanding and difficult task 4852 Evaluation (n=117) *P<0.05

31. Quality Education for a Healthier Scotland Early Feedback from SEA Peer Reviewers Subjective/Objective Comparisons – ‘Old’ vs ‘New’ Acts as a ‘forcing function’ – deeper analysis More straightforward to actually understand and peer assess Feeling that more challenging events are being selected Overall standard has improved compared with ‘old’ system

32. Quality Education for a Healthier Scotland “normal” vs “enhanced” SEA

33. Quality Education for a Healthier Scotland Overall Impact of enhancedSEA “I think it was definitely the most thorough SEA that we’ve done for a while and everybody commented that it went very well and it had some very good outcomes for us all things that I really think will have a decent impact” “I think it’ll get people to think more into just why significant event analysis happens and it’s like a big elephant in the room, of course you’re embarrassed and you will have these emotions and I think it encourages people to realise that those emotions are there, we’re not working as robots if you like. And it gets people to think more about being human”

34. Quality Education for a Healthier Scotland Overall Impact of enhanced SEA “I found it made the process more laborious and confusing in some ways. I think the booklet was helpful but the report format needs to be simplified. Some of it felt like writing in order to fill in boxes. I think we would have come to the same conclusions if I had used our normal format”.

35. Quality Education for a Healthier Scotland SEA unopposed oestrogen HRT 50 year old lady No period in 18 months Attended ST3 requesting HRT patch Prescribed Evorel 25. HRT review 1 month later with nurse – inadequate control symptoms PC with ST3– increased to Evorel 50

36. Quality Education for a Healthier Scotland Unopposed oestrogen Review with nurse 1 month later – HRT review performed and recorded 3 month prescription printed and GP asked to sign between patients Review with nurse 3 months later Further 3 month prescription and again signed by GP between patients.

37. Quality Education for a Healthier Scotland Unopposed oestrogen Attended GP partner feeling tired Reported 3 months of heavy PV bleeding GP double checked HRT – Apologised – Gynaecology referral – USS

38. Quality Education for a Healthier Scotland Consider personal impact on ST3 “Devastated” Loss of confidence Was very worried about discussing at SEA meeting

39. Quality Education for a Healthier Scotland What would their first thoughts be? Probably – Guilt – Self blame – Educational need – “Will try not to do this again.”

40. Quality Education for a Healthier Scotland Consider impact Patient Other patients Practice

41. Quality Education for a Healthier Scotland Consider people factors Patient ST3 - Training Nurse – training, experience GP who signed prescription

42. Quality Education for a Healthier Scotland Consider activity HRT review EMIS prescribing EMIS template System in place for getting prescription signed

43. Quality Education for a Healthier Scotland Consider environment Busy surgery 10 minute appointment for HRT review GP signing prescription between patients – Unlikely to check – Unlikely to question Training

44. Quality Education for a Healthier Scotland How did this combine? Easy mistake to make due to systems (EMIS) Time pressure (ST3, GP, nurse) Trying to save patient delay Simple mistake not picked up

45. Quality Education for a Healthier Scotland Action plan Apology EMIS warning HRT template on EMIS with box to check type of HRT Include HRT in “high risk” medicines tutorial at start of training Have practice “preferred list” of HRT in each room Training of GPs and nursing staff Regular audit - monthly Nominate who is responsible for each action

46. Quality Education for a Healthier Scotland Enhanced SEA - Summary Enhanced SEA helps – Discuss “difficult SEAs” which are often PSIs – Get to the bottom of WHY the event happened Exploring people, activity and environment – Develop and action plan to reduce the risk of recurrence

47. Quality Education for a Healthier Scotland QUESTIONS?

48. Quality Education for a Healthier Scotland Enhanced SEA – more information www.nes.scot.nhs.uk/shine/