Practical Patient Safety PDF
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Practical Patient Safety This page intentionally left blank Practical Patient Safety By John Reynard DM FRCS Urol Consultant Urological Surgeon, Department of Urology The Churchill Hospital, Oxford, UK and Honorary Consultant Urological Surgeon The National Spinal Injuries Centre Stoke Mandeville Hospital, Buckinghamshire UK John Reynolds DPhil FRCP Consultant Physician and Clinical Pharmacologist, John Radcliffe Hospital, Oxford Peter Stevenson Commercial Airline Pilot and Honorary Patient Safety Lecturer, Nuffield Department of Surgery, University of Oxford 1 1 Great Clarendon Street,Oxford OX2 6DP Oxford University Press is a department ofthe University ofOxford. It furthers the University’s objective ofexcellence in research,scholarship, and education by publishing worldwide in Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark ofOxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc.,New York © Oxford University Press 2009 The moral rights ofthe author have been asserted Database right Oxford University Press (maker) First published 2009 All rights reserved.No part ofthis publication may be reproduced, stored in a retrieval system,or transmitted,in any form or by any means, without the prior permission in writing ofOxford University Press, or as expressly permitted by law,or under terms agreed with the appropriate reprographics rights organization.Enquiries concerning reproduction outside the scope ofthe above should be sent to the Rights Department, Oxford University Press,at the address above You must not circulate this book in any other binding or cover and you must impose the same condition on any acquirer British Library Cataloguing in Publication Data Data available Library ofCongress Cataloging in Publication Data Data available Typeset in Minion by Cepha Imaging Pvt.Ltd.,Bangalore,India Printed by Biddles Ltd.King’s Lynn,Norfolk,UK ISBN 978-0-19-923993-1 (Pbk) 10 9 8 7 6 5 4 3 2 1 This book is dedicated to Elaine Bromiley,victim of an unintended human error during a routine operation;and to her team of clinicians who did their best but were never given the opportunity to learn about human factors,human error and good non-technical skills until they had the lesson for real. This page intentionally left blank Preface In 2006,Elaine Bromiley,a healthy 37-year-old woman was booked in for non-emergency sinus surgery.The theatre was very well equipped.The ENT surgeon had 30 years experience and the consultant anaesthetist had 16 years experience.Three ofthe four nurses in theatre were also very experienced. Anaesthesia was induced at 8.35 a.m.but it was not possible to insert the laryngeal mask airway.By 8.37 a.m.oxygenation began to deteriorate and the patient became cyanosed.At 8.39 a.m.the oxygen saturation level had fallen to 40%.Attempts to ventilate the lungs with 100% oxygen using a facemask and oral airway proved extremely difficult.The oxygen saturation level remained perilously low and the anaesthetist who was joined by another consultant colleague was unable to perform a tracheal intubation. By 8.45 a.m.airway access still had not been achieved and a situation existed that was termed ‘can’t intubate,can’t ventilate’.This is a recognized emergency for which a guideline exists-to perform an emergency tracheotomy. Anticipating the need for an emergency tracheotomy,a nurse went to fetch the tracheotomy equipment.A second nurse phoned through to the intensive care unit to check there was a spare bed available. The growing stress ofthe situation apparently caused the surgeon and the anaesthetists to lose awareness ofhow long they had been attempting to insert the tube. The nurse who fetched the tracheotomy kit told the medical team it was available but none ofthe consultants subsequently recalled her speaking to them (probably due to fixation and stress).The nurse who phoned ICU addressed the consultants explaining ‘There’s a bed available in Intensive Care’, but to quote from the Inquest they looked at her as if to say ‘what’s wrong? You’re over-reacting.’The nurse concerned cancelled the bed with ICU, although she stated that she instinctively felt that the consultants were mis-managing the patient’s care. The three consultants decided to continue attempts at intubation,but at 9.10 a.m.they abandoned the procedure hoping that the patient would wake up.Her oxygen level remained below 40% for 20 minutes and she never regained consciousness.She died 13 days later. Ifthe experience ofElaine’s family was an isolated one it would be tragedy enough.But it is not.Over the last few years the general public and the media viii PREFACE have become increasingly aware of the concept of clinical error leading to patient harm.In the UK alone it has been estimated that 40 000 patients die every year as a consequence of clinical error—something their doctors or nurses did to them that led directly to their death.This is the dramatic tip of the iceberg,but below the surface lurks an even larger ‘mass’ofharm leadingto prolonged hospital admission or permanent disability. However one looks at it,error leading to an adverse event (patient harm) represents a failure ofthe system or ofindividuals or ofboth.Reflection on failure is almost always a painful exercise,but in every cloud there is a silver lining.The study of failure gives us the opportunity of learning and of avoiding failure in the future.The key is to learn from the mistakes ofothers. To paraphrase Bismarck:‘Only a fool learns from his own mistakes.The wise man learns from the mistakes ofothers.’ Unfortunately,for whatever reason,many ofus,whether doctors,nurses,or hospital managers,are forced to learn from our own bitter experiences as healthcare systems are notoriously bad at translating the experience oferror into preventative methods.In the foreword ofthe Healthcare Commission’s 2006 Report into the Clostridium difficileoutbreak at Stoke Mandeville Hospital,Sir Ian Kennedy recalled that he had notbeen able to say with confi- dence in the immediate aftermath of the Bristol Babies enquiry that such events would never happen again.The Stoke Mandeville experience proved his concerns to be correct and led him to state:‘It is a matter of regret that the lessons ofBristol have not been learned and incorporated into every corner of the NHS.’ Our intention in writing this book is to provide the reader with error pre- vention tools.These tools have been designed to incorporate the lessons learned by other unfortunate doctors and nurses who have committed errors, so that the same path towards error and adverse events can be avoided.Thus, much ofthe book is taken up by an analysis ofaccidents that have happened in healthcare and other ‘industries’because we are convinced that an under- standing ofhow error occurs is fundamental to being able to prevent error. Although human error might appear to have limitless configurations,in reality the way in which humans commit error can be distilled down to a few fundamentals.Thus,we believe that the patient safety tools described in this book can be used most effectively ifthe user knows how and why the tool was created in the first place. The clinician authors have been fortunate indeed to have had the world of the airline pilot opened up to them through their co-author,Peter Stevenson. We have learnt about the techniques employed by airline pilots to enhance safety in what is potentially a high-risk environment (flying wide body PREFACE ix passenger airliners),but which in reality is nowadays one ofthe safest forms of mass transportation.Such techniques are so obviously sensible,and failure to observe them so obviously central to the development of many errors that have occurred in the past in the transport,nuclear,and petrochemical indus- tries (nowadays called high reliability organizations) that the authors believe that they should be taught to all healthcare workers as so many ofthe human errors ofdoctors and nurses mirror errors in these industries.This then is the essential purpose behind writing this book—to translate high reliability organization safety principles and techniques into the healthcare situation. Ofcourse,healthcare differs in several important aspects to flying aircraft. Patients are often very sick and therefore vulnerable,the ‘operations’of healthcare organizations are enormously diverse and emergencies are com- monplace.Added to this is the fact that,whereas the number of staff to be trained in airline safety techniques is relatively small (the ratio of aircrew to passengers numbers is very low),there is a greater balance between the numbers of patients and carers because healthcare is often delivered on a one-to-one basis—doctor to patient,nurse to patient.Thus,healthcare organ- izations are faced with the challenge ofeducating enormous numbers ofdoc- tors and nurses across a wide range oforganizations and areas.Add to all this the sometimes unpredictable behaviour ofpatients and the potential for error on a large scale becomes obvious. Despite these differences between planes and patients,important similarities exist between the types oferrors that have occurred in the cockpits ofpassen- ger airliners,on oil rigs,on cross-channel ferries,and in the driver’s cabs of passenger trains and those that occur on hospital wards and in operating the- atres.These similarities relate to the fact that all these organizations rely on humans to run them and humans commit errors in a relatively limited num- ber of ways.Aspects of human behaviour that lead to error are universal— whether the human being happens to be a pilot,a nurse,a physician,or a surgeon.Many ofthe safety techniques learnt by pilots and workers in other high reliability organizations relate to the way in which human errorcan be prevented.Pilots commit slips,lapses,and mistakes just as doctors do,but they are equipped with tools to help them recognize potential and evolving errors,so preventing them from occurring or mitigating their effect once they have occurred.For this reason,the safety track record ofmodern airlines and other high reliability organizations has improved dramatically over the last 20 years or so.The same cannot be said ofhealthcare. When we talk about these techniques oferror reduction,doctors sometimes say to us,‘yes,but where’s the evidence?’In recent years the medical profession has (in many cases quite appropriately) become locked into the concept of
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