‘THE SWISS CHEESE EFFECT ‘ OR RISK MANAGEMENT Lynn Randall Clinical Risk & Quality Co-ordinator Children’s Hospital University Hospitals of Leicester NHS Trust
Where do we find risks? • Risks are all around, but often we fail to see them as our workplace environment becomes more or less background noise. • Complacency is our enemy and therefore each patient’s enemy
Risk’s in the Neonatal Unit Name me 10 Risks that you may encounter on a daily basis? - Needle stick injuries - No cots - Lack of sufficient numbers of qualified Neonatal Staff - Deteriorating Babies - Lack of domestic staff – wet floors - Infection of babies – cross infection - Over capacity - Labour ward wanting to deliver babies – ‘no room in the inn’ - Cardiac babies being delivered - no beds NNU or PICU - Lack of medical staff of all grades - Environmental Concerns - Over heating of unit - Fire – how to evacuate - Security – aggressive/agitated parents relatives This is without the unusual – swarms of Ants / Bees; Squirrels entering the building
Patient Safety “It may seem a strange principle to enunciate, as the very first requirement in a hospital, that it should do the sick no harm” Florence Nightingale
QUALITY AND SAFETY THE BACKGROUND (Often referred to as Clinical Governance, Patient Safety, Clinical Risk) Number and Severity of “clinical disasters” Failure of NHS Trusts to act – in the face of a pattern of poor care Cost of lawsuits and media coverage
Healthcare is complicated, too complicated for any one person to actually own or control the processes of diagnosis and care. Patients come into our hospitals for care, and for their benefit and safety we all need to look upon ourselves as part of the “system” of care.
All who work in the system, regardless of their qualifications or role, must recognise that they are part of a very large team who all have but one objective, the proper care and treatment of their patients. Robert Francis 2012
Effective Clinical Governance Should Guarantee: • Baby's parents have all the information they need about the care provided • Clinical errors are prevented whenever possible • Staff treat baby’s and parents courteously and involve them in decisions • The Neonatal services are continuously being improved and updated • Health care professionals are up to date in their practices
Effective Clinical Governance Should Guarantee : • Care is based upon the best evidence available • Good information systems are available to support all aspects of clinical care • Clinical practice is routinely monitored and changes made as necessary
Clinical Governance / Risk Management Clinical Governance Clinical Risk Management Complaints / Incidents Education & Training Evidence – Based Practices & Guidelines Accreditation Procedures Clinical Audit
D u n t o m t i n c e a o
What Does It Mean? NBM BW PU AKA BS ARM PID AOB RA BM EDD CCU
Medical Jaggon All health care professionals have their own language. Do we as nurses understand all of what are medical colleagues are saying to us. Do we query it or do we just except it – ensuring that we do not look like an idiot! This is both verbal and written communication. Do our colleagues, parents and relatives understand what we are trying to tell them?
If it isn’t written down it didn’t happen!
Currently our Coroner – Mrs Masons, Leicester one of her favourite phrases. A court of law will tend to assume that if care has not been recorded then it has not been given.
Reporting of Your Concerns Where you have a concern related to any of the following. You need to escalate your concerns and complete an incident form. But why? : - Care of the babies on your unit An event that has happened on the unit The numbers of staff to care for the babies – at all levels An error involving the treatment and care of the baby(s) The environment The equipment used Any concern you have in relation to the care you provide, witness or have concerns with .
GRADING ALL INCIDENTS All incidents must be graded according to the impact on patient care, potential future risk to patients or staff, and the organisation as a whole. An immediate assessment of the consequence of the incident should be undertaken using the following categories: Grade Description • None No harm, loss or damage • Minor Non permanent harm (increased length of stay > 7 days/injury requiring first aid) • Moderate Semi permanent harm (increased length of stay 8-15 days/RIDDOR, staff absence > 3 Days) • Major Major permanent harm (increased length of stay > 15 days/single patient death) • Extreme - Multiple patient death or serial incidents. - Single staff/visitor/contractor death
Swiss Cheese Effect http://www.rcn.org.uk/development/practice/cpd_online_learning/making_sense_of_patient_ safety/core_concepts_in_patient_safety
SUI (Serious Untoward Incident) SUI’s in health care are adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified
SUI - examples • Unexpected or avoidable death of one or more people. • Unexpected or avoidable injury to one or more people that has resulted in serious harm • Unexpected or avoidable injury that requires further treatment by a healthcare professional in order to prevent the death of the service user; or serious harm • Actual or alleged abuse /Safeguarding • A Never Event • An incident/s that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services • Major loss of confidence in the service, including prolonged adverse media coverage or public concern about the quality of healthcare or an organisation
Your Responsibilities Following a serious incident • Report appropriately • Continue to care for the patient • Complete Datix form • Report to appropriate member of staff NIC / Doctor • Inform parent and family – Duty of Candour- Being Open Leaflet (only given once escalated as SUI) • Record in notes and ensure any subsequent review of the baby is documented. • Make some notes of your own at the time • Provide a statement if requested to do so in a timely manner • Attend an investigatory meeting as requested (jigsaw pieces)
DUTY OF CANDOUR • From October 2014, NHS providers will be required to comply with the duty of candour. Meaning providers must be open and transparent with service users about their care and treatment, including when it goes wrong • Patients have the right to be informed if they are involved in any incident that is graded as moderate or above. This should be reflected in the notes and on Datix as well as apologies • Failure to comply with this incurs a financial penalty of £10,000 per incident
COMPLAINTS
How do Complaints help our Practice? Complaints are an opportunity to understand how we are perceived by our parents and relatives They give us the opportunity to improve the care we provide They give us the opportunity to improve our communication with the parents and families They help us to understand what went well and what went wrong
Classification of Complaints Formal Verbal CCG/PCT Concern Request for Information Staff GP CQC
Complaints • ‘Why do the Drs speak to me as if I am something they have stepped in!. When I viewed my baby’s notes it was full of things that were never discussed with me’ • The member of staff was so rough and rude and never explained what they were going to do. They would not listen to what I had to say’
Patients Perception • Baby waiting for an operation for 2 days, which keeps being cancelled as the Theatre has too many emergencies and is apparently too busy. Another Baby came in and was taken to theatre the same day – why?. • Conflicting advice given by different teams
If it isn’t written down it didn’t happen!
Finally- Remember • Communication • Duty of Candour • Consistent Information • Honesty to Organisation • Incident reporting to enable identification of trends, common themes and put appropriate actions in place. Also to identify where systems not effective. • Purpose of SUI investigation is to analyse the information and evidence available to determine the underlying cause and lessons to be learned.
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