A CASUAL OBSERVATION

A CAUSAL OBSERVATION

I undertook outpatient phenol sclerotherapy for symptomatic second degree haemorrhoids on a 58 year old lady. I use oily phenol 5% BP w/v, and injected 2-3ml at 4 sites into the submucosal area at the base of each pile, above the dentate line. On this occasion, I was passed the phenol already prepared in a syringe. I didn’t check the phenol composition but it was subsequently determined to be an 80% aqueous solution. Post-injection, the patient developed necrosis at the upper border of the ano-rectal canal, which necessitated surgical debridement and defunctioning end-colostomy. The colostomy was eventually restored successfully with full patient recovery after some months.

Source: CORESS, Royal College of Surgeons England, March 2010

Week 1 – retained swab

Week 3 – retained instrument

Week 4 – wrong site

Week 6 – wrong implant

SURGICAL ERROR:

A WORLDWIDE PHENOMENON

January – wrong site neurosurgery

July – wrong site neurosurgery

November – wrong site neurosurgery

SURGICAL ERROR: A WORLDWIDE PHENOMENON

LAC-MÉGANTIC: ANATOMY OF A

DISASTER

STORIES FROM THE HEART

THE SEEDS OF DESTRUCTION

PRE-FILLED SYRINGE CONTAINING VINCRISTINE

ILLUSTRATING THE WARNING WRITTEN IN BLUE TEXT

WHO IS TO BLAME?

STORIES FROM THE HEART

Tragic

death

Team culture Fully-trained

staff

Procedural

guidelines

THE GAPS

Professionalism

of staff

Good

communication

Not followed

Insufficient experience

Hierarchial attitudes

Inappropriate attitude

Risks not highlighted

DEFENCES

PROMOTING SYSTEMS THINKING

NASOGASTRIC TUBE INCIDENTS

REPORTED AS ‘NEVER EVENTS’

Source: NHS England

2012/2013: 20 cases

2013/2014: 14 cases

PATIENT SAFETY – THE TURNING POINT

Apathy

Incidents

seen as

parochial

events

Disinterest

Patient safety

was the

domain of

academics and

enthusiasts

THE STATE OF SAFETY IN HEALTHCARE

AT THE BEGINNING OF THIS CENTURY

Condescension

Information

withheld

from victims

Ignorance

Scale of

problem

unrecognised

Arrogance

It could not

happen here

© Sir Liam Donaldson

PATIENT SAFETY INCIDENT

REPORTS IN ENGLAND AND WALES

Source: The National Reporting and Learning System

PATIENT SAFETY INCIDENTS

REPORTED IN THE NHS

Source: The National Reporting and Learning System

Deaths

(31,600)

Severe harm

(67,400)

Moderate harm (624,000)

Low harm(2.55M)

No harm (6.97M)

“Commenced night shift short-staffed. Dr in charge was a

locum, newly qualified and unable to administer IV

medications. RN is agency nurse. Only saw 2 out of 10

patients. Dept over full with many patients on trolleys.

Shift was unsafe with reduced numbers of staff, who were

inexperienced and lacking skills.”

Source: NRLS

EXTRACT FROM PATIENT SAFETY

INCIDENT REPORT

THINKING SYSTEMS: INTERFACES

AND INTERACTIONS

ENVIRONMENT

PEOPLE

PROCEDURES MACHINES

Source: Donaldsons’ Essential Public Health. London: Radcliffe, 2016

TEAMS DETERMINE SURVIVAL AND DEATH

PROTECTION PATIENTS: THREE PILLARS

Identifying

harm

Learning

from error

Improving

safety

PATIENT SAFETY GOES GLOBAL

PROGRESS OVER THE LAST DECADE

Systems thinking

Scale of problem recognised

Human factors appreciated

Successful campaigns

Growth of simulation

DISAPPOINTMENTS OVER THE LAST

DECADE

Few actionable data

Lack of effective solutions

Limited practitioner interest

Patients seldom involved

Risk not communicated widely

Clinical Staff take a wider perspective on their work.

Acceptance of standardising practice in some areas.

Problem-solving culture.

Quality plan and business plan are one and the same.

Involvement of patients and families.

Good use of data.

KEY FACTORS FOR SUCCESS

1:300 1:10,000,000

COMMERCIAL AVIATION VERSUS

HEALTHCARE: COMPARATIVE RISKS

Source: Donaldson L. When will healthcare pass the orange-wire test? The Lancet 2004;

364: 1567-1568

GLOBAL ACTION TO SAVE LIVES