Patient Safety E-Book

Charles Vincent

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 837

Veröffentlichungsjahr: 2011

Beschreibung

When you are ready to implement measures to improve patient safety, this is the book to consult. Charles Vincent, one of the world's pioneers in patient safety, discusses each and every aspect clearly and compellingly. He reviews the evidence of risks and harms to patients, and he provides practical guidance on implementing safer practices in health care. The second edition puts greater emphasis on this practical side. Examples of team based initiatives show how patient safety can be improved by changing practices, both cultural and technological, throughout whole organisations. Not only does this benefit patients; it also impacts positively on health care delivery, with consequent savings in the economy. Patient Safety has been praised as a gateway to understanding the subject. This second edition is more than that - it is a revelation of the pervading influence of health care errors, and a guide to how these can be overcome. "... The beauty of this book is that it describes the complexity of patient safety in a simple coherent way and captures the breadth of issues that encompass this fascinating field. The author provides numerous ways in which the reader can take this subject further with links to the international world of patient safety and evidence based research... One of the most difficult aspects of patient safety is that of implementation of safer practices and sustained change. Charles Vincent, through this book, provides all who read it clear examples to help with these challenges" From a review in Hospital Medicine by Dr Suzette Woodward, Director of Patient Safety. Access 'Essentials of Patient Safety - Free Online Introduction': www.wiley.com/go/vincent/patientsafety/essentials

Leseprobe

Contents

Preface

The nature of the book

Inspiration, acknowledgements and thanks

SECTION ONE The Evolution of Patient Safety

CHAPTER 1 Medical harm: a brief history

The cure can be worse than the disease

Heroic medicine and natural healing

Hospitalism and hospital acquired infection

Surgical errors and surgical outcome

Iatrogenic disease

Systematic studies of the hazards of hospitalization

Medical nemesis

References

CHAPTER 2 The emergence of patient safety

Improving the quality of healthcare

Learning from error

Tragedy and opportunities for change

Studying the safety of anaesthesia: engineering a solution

Error in medicine

Litigation and risk management

Professional and government reports: patient safety hits the headlines

An organization with a memory: learning from adverse events in the NHS

References

CHAPTER 3 Integrating safety and quality

Defining patient safety

Patient safety – reducing harm or reducing error?

What is quality?

The quality chasm

The relationship between safety and quality

When does a quality issue become a safety issue?

What has safety brought to quality?

Safety and quality research

References

SECTION TWO The Hazards of Healthcare

CHAPTER 4 The nature and scale of error and harm

Studying errors and adverse events

Methods of study

Hindsight bias

Studying adverse events using case record review

The impact and cost of adverse events

Complications and adverse events in surgery

Deaths from adverse events: can we believe the findings of retrospective record review?

Hospital acquired infection

Injection safety in developing countries

Studies of medication errors and adverse drug events

Medication errors

Adverse drug events

Vulnerability to harm: the old and the frail

The vulnerability of the very young

References

CHAPTER 5 Reporting and learning systems

Varieties of healthcare reporting systems

Aviation, aerospace and nuclear reporting and learning systems

Reporting systems in healthcare

Local reporting systems

Specialty reporting systems

National and other large-scale systems

Do healthcare reporting systems reflect the underlying rate of incidents?

Using multiple information systems

Barriers to reporting

Feedback and action

Reporting, surveillance and beyond

References

CHAPTER 6 Measuring safety

The critical role of measurement

Defining measures of safety

Structure, process and outcome: what measures best reflect safety?

Structural measures

Outcome measures

Process measures

Intervening variables

The integration of safety and quality at the process level

Approaches to the measurement of safety

Systematic record review

The global trigger tool

Mandatory reporting of never events

Safety indicators: using routine data

Targets, standards and the unexpected consequences of measurement

Tracking safety over time: are patients any safer?

Hospital standardized mortality

Mortality following surgery

Healthcare acquired infections

Medication errors and adverse drug events

References

SECTION THREE From Accident Analysis to System Design

CHAPTER 7 Human error and systems thinking

The lessons of major accidents

Is healthcare like other industries?

Differences between healthcare and other industries

The organization of safety in healthcare and other industries

What is error?

Defining error

Classifying errors

Describing and classifying error in medicine

Prescribing error

Diagnostic errors

Examples Commentonerror

The psychology of error

Slips and lapses

Mistakes

Violations

Perspectives on error and error reduction

Engineering perspective

Individual perspective: the person model

Organizational perspective: the system model

Error, blame and censure

The concept of error: is it useful for the design of safe healthcare systems?

References

CHAPTER 8 Understanding how things go wrong

Background to the incident

Death from spinal injection: a window on the system

Assumption that the system was reliable

Assumptions about people

The influence of hierarchy on communication

Physical appearance of syringes containing cytotoxic drugs

Unnecessary differences in practice between hospitals

Aetiology of ‘organizational’ accidents

Seven levels of safety

The investigation and analysis of clinical incidents

Methods of investigation

Systems analysis or root cause analysis?

Systems analysis of clinical incidents: the London Protocol

An illustrative case example

Human reliability analysis

Techniques of human reliability analysis

Failure modes and effects analysis (FMEA)

Integration and evaluation of analytic techniques

From accident analysis to system design

References

SECTION FOUR The Aftermath

CHAPTER 9 Caring for patients harmed by treatment

Injury from medical treatment is different from other injures

The impact of medical injury

The experiences of injured patients and their relatives

What do injured patients need?

Being open: patients’ and physicians’ attitudes to disclosing error

Open disclosure: policy and practice

Barriers to open disclosure

Breaking the news about error and harm

In the longer term

Compassion in action

References

CHAPTER 10 Supporting staff after serious incidents

The experience of error

The wider impact on clinical staff

What makes an error traumatic?

The impact of litigation

Strategies for coping with error, harm and their aftermath

References

SECTION FIVE Design, Technology and Standardization

CHAPTER 11 Clinical interventions and process improvement

Two visions of safety

Clinical practices to improve safety

Evidence based medicine meets patient safety

Quality management and process improvement

Simplifying and standardizing the processes of healthcare

Waste, delay and rework

Reducing medication error

Positive personal characteristics can inhibit process improvement

References

CHAPTER 12 Design for patient safety

Design and error

Design for safer healthcare

Designing out medication error

Re-designing the resuscitation trolley

Designing out hospital acquired infection

Whole system design

References

CHAPTER 13 Using information technology to reduce error

The limits of memory

Judgement and decision making

Using information technology to reduce medication errors

Communication and alerts

Forcing functions and corollary orders

Electronic medical records

Decision support

Patients’ response to decision support

The implementation of information technology

The unintended consequences of information technology

The ironies of automation

Inflexibility and rigidity

Integration within the work process

A false sense of security

References

SECTION SIX People Create Safety

CHAPTER 14 Creating a culture of safety

The many facets of safety culture in healthcare

Organizational culture

Organizational culture and group culture

Safety culture

An open and fair culture

Assessing culpability: the incident decision tree

A culture of learning

Flexibility and resilience: the culture of high reliability

The lessons of high reliability organizations (HRO)

Reflections on high reliability research

Measuring safety culture

Can we change the culture?

And if we can change the culture, will patients be any safer?

References

CHAPTER 15 Patient involvement in patient safety

Patients as active participants in their care

The patient’s role in patient safety

Patient involvement in patient safety: fundamental issues

Patients’ willingness to engage in safety practices

Patients reporting of adverse events

Safety interventions: collaboration between patients and professionals

Hand hygiene

Patients for patient safety

References

CHAPTER 16 Procedures, violations and migrations

Creating safety by following rules and procedures

Breaking the rules and bucking the system

Understanding deviations from procedures

A theory of migrations and violations

The natural lifespan of a safety rule

Managing violations in the clinical team

Procedures are an ideal world

References

CHAPTER 17 Safety skills

Safety skills, attitudes and behaviour in industry

Safety skills in healthcare

Putting on your second hat: awareness of fallibility and hazard

Safety and non-technical skills

Situation awareness

Anticipation and vigilance

Decision making

Training in decision making

The influence of working conditions

References

CHAPTER 18 Teams create safety

What is a team?

Why work in teams?

Teams and safety

Watching what goes on: observing teamwork

Team leadership

Leadership skills

Team interventions: briefing, checklisting and daily goals

Clarity and communication: the adoption of daily goals

Briefing and checklisting in surgery

Formula 1 and post-operative handover

Redesigning the wider team

Team training for safety

Assessing teamwork

Simulation

Emergency medicine: team training to reduce error

Leadership and learning: how do teams train themselves?

References

SECTION SEVEN The Journey to Safety

CHAPTER 19 Safe organizations: bringing it all together

Clinical microsystems

The evaluation of complex interventions

A hospital is a complex adaptive system

The intervention evolves over time

Measurement of impact

Improving the safety of intensive care

Foundations of improvement

Translating evidence into practice

The keystone project: state wide harm reduction

The Safer Patients Initiative

The safer patients programme

Ready for improvement?

The impact of SPI

Engagement and motivation

Process improvement

Patient outcomes and system change

On the campaign trail

References

CHAPTER 20 High performing healthcare systems

Conditions and drivers of change

Leading system change

High performing healthcare systems

Veterans Affairs, New England

Standardization and systematization

Performance measurement and accountability

Electronic medical records and decision support

Systems for implementing change

Jonkoping County

Sustained leadership and commitment

Esther

Qulturum: centre for learning and culture

Engagement and spread

A quality strategy

Styles and strategies for system improvement

Investing for the long term

Making a Swiss watch from a Swiss cheese

References

Index

Frontispiece

‘The greatest benefit to mankind’.

(Samuel Johnson’s tribute to medicine)

‘It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm’.

(Notes on Hospitals, Florence Nightingale, 1863).

This second edition is published 2010, © 2010 by Charles Vincent

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First published © Elsevier Limited 2006

Library of Congress Cataloging-in-Publication Data

Vincent, Charles, Dr.

Patient safety / Charles Vincent - 2nd ed.

p. cm.

Includes bibliographical references and index.

ISBN 978-1-4051-9221-7 (pbk.)

1. Medical errors 2. Iatrogenic diseases 3. Hospitals-Safety measures. I. Title. [DNLM: 1. Patient Care-standards. 2. Quality of Health Care-standards. 3. Medical Errors-prevention & control. 4. Safety Management-standards. W 84.41 V769p 2010]

R729.8.V56 2010

610.28’9-dc22

2010003436

For Angela

Preface

Patient safety is the foundation of good patient care. The unnerving fact that healthcare can harm us as well as heal us is the reason for suggesting that patient safety is the heart of healthcare quality. Effectiveness, access to care, timeliness and the other dimensions of quality are all important. But when a member of your family goes into hospital or receives other healthcare then above all you want them to be safe. There is something horrifying about being harmed, or indeed causing harm, in an environment of care and trust. Both for patients and staff, safety is the emotional heart of healthcare quality. I also believe in terms of understanding, improvement and day-to-day running of healthcare that safety is a touchstone and guide to the care that is given to the patients; the clinician or the organization that keeps safety to the fore in the midst of the many other often competing priorities achieves something remarkable and provides the care that we would all want to receive.

Why though, even if you accept this perspective, should you read a book on patient safety? The first reason is very simple: the importance of the topic. As you will see if you read on, there is compelling evidence that, while healthcare brings enormous benefits to us all, errors are common and patients are frequently harmed. The nature and scale of this harm is hard to comprehend. It is made up, worldwide, of hundreds of thousands of individual tragedies every year, in which patients are traumatized, suffer unnecessary pain, are left disabled or die. Many more people have their care interrupted or delayed by minor errors and problems; these incidents are not as serious for patients but are a massive and relentless drain on scarce healthcare resources.

A second reason is that for all the books, reports, articles and Websites devoted to patient safety, there is still no straightforward overview of the field. The books that are available are mostly multi-author edited texts which, while they bring a rich diversity of perspective, are not primarily aimed at explaining the basic principles, characteristics and direction of the field. My aim has been to show the landscape of patient safety: how it evolved, the research that underpins the area, the key conceptual issues that have to be addressed, and the practical action needed to reduce error and harm and, when harm does occur, to help those involved.

Third, patient safety is a meeting point for a multitude of other topics. The relevant literature is difficult to grasp, being scattered, diverse and multidisciplinary in nature. Much of it is published in areas, such as cognitive psychology and ergonomics, which are unfamiliar to medicine. Worse still, many of the topics fundamental to progress in patient safety are themselves the subjects of huge literatures and much debate. For instance, a substantial amount of work has been carried out, from a number of different perspectives, on the factors that produce safe, high performing teams. The same could be said of expertise, decision making, human error, human factors, information technology, leadership, organizational culture … the list goes on and on.

A fourth reason is to show that patient safety is, very simply, a tough problem in cultural, technical, clinical and psychological terms, not to mention its massive scale and heterogeneity. Healthcare is the largest industry in the world and extraordinarily diverse in terms of the activities involved and the manner of its delivery. We are faced with hugely intractable, multifaceted problems, which are deeply embedded within our healthcare systems. Understanding this is both an intellectual and a practical challenge. One of the greatest obstacles to progress on patient safety is, paradoxically, the attraction of neat solutions, whether political, organizational or clinical.

The nature of the book

I hope that this book can be read by anyone either interested or involved in healthcare, as an introduction to patient safety or to deepen their knowledge of specific topics. I have tried to write a clear and comprehensive overview of the major themes while not shying away from the difficulties, controversies and challenges. To my mind the attempt, in many papers and conferences, to present all quality and safety issues in the simplest possible terms has been a disaster and a major obstacle both to progress generally and specifically to the engagement of clinicians. I have also tried to make the book a gateway into the field. Some truly wonderful books and papers have been written about patient safety, or topics relevant to it, and I have tried to show my own sources of inspiration and learning and direct people to them.

A book of this kind is inevitably highly selective and some decisions have to be made about what to cover and in how much detail. I have tried, as far as possible, to address generic issues that cross specialties and disciplinary boundaries, rather than examine a series of specific clinical topics. I believe this approach brings a greater understanding and enables the reader to take the basic principles and apply them in whatever setting they work in. I have, however, included illustrations and specific clinical examples wherever possible, aiming to balance and illuminate the more general points. Patient safety is still largely confined to hospital medicine and to the developed world, and the book reflects this. Safety in primary care, mental health, care given in the home and patient safety in developing countries are vital issues, but work on them has hardly begun.

The second edition of this book is very different from the first, reflecting developments in both the field and my own understanding. In 2005 I was able to write that most safety improvement programmes were, to my mind, rather haphazard and without defined direction or purpose. That was true then, but no longer. The entire second half of this book discusses how healthcare can be made safer and contains a host of examples and illustrations of improvements to the safety and quality of care.

The book is designed to be read straight through, though readers who wish to address particular themes and topics can select specific sections. The first half of the book discusses the nature of safety and the essential understanding that is needed before improvements can be made The first section of three chapters addresses the history and evolution of patient safety and the vexed question of how safety relates to quality. Patient safety emerged from a particular historical context; understanding how it emerged is the best way, to my mind, to understand its character, strengths and limitations. The next three chapters address the nature and scale of harm, examining the research evidence, the role of reporting systems and the neglected topic of measurement of safety. Chapters 7 and 8 form another section devoted to understanding why errors and accidents happen, reviewing the concept of human error, the nature of accidents, perspectives on safety and methods of analysing incidents. The following two chapters consider the impact of errors and harm on the people involved, patients and their families in Chapter 9 and clinical staff in Chapter 10.

The chapters in the second half of the book, all in one way or another concern the reduction of error and the ultimate aim of safe, reliable healthcare. The fifth section opens with a discussion of ways in which clinical processes can be improved, rooted in well established methods of quality improvement in both healthcare and manufacturing industries. The next chapter considers the new, but potentially very fruitful, role of design in patient safety followed by a discussion of the critical role of information technology. Section 6, consisting of five chapters, complements these technological solutions by addressing the different ways that people, both patients and staff, can either erode or create safety, both as individuals and as teams. Two final chapters consider how all these component parts can be integrated to bring us safer organizations and safer healthcare systems.

The fact that a quarter of this book is devoted to the many ways in which people individually or within teams actively create safety reflects my own belief that anyone in any discipline and at any level in healthcare can improve the safety of care. Systems and processes are important but in the end people make the difference. I hope this book may be of some help to you.

Inspiration, acknowledgements and thanks

Many people, whether they know it or not, have helped in the writing of this book. In the first edition I listed a number of people who through their actions, their writings or their conversation had expanded my view or changed the way I think about patient safety. Even then it was a long list but now it is impossibly long and so I will simply say that the list of references and sources is testament to the richness of the patient safety literature and that I am indebted to everyone named there. As before, however, I will single out two people, Lucian Leape and James Reason, who require special mention both because of their influence on the field and the help they have given to me personally. Both have been an inspiration and unfailingly generous in their support and encouragement.

I also wish to thank the following people for their contribution to the book. Rachel Davis provided exemplary help, encouragement and tactful criticism during the writing; Katrina Brown, Susannah Long, Krishna Moorthy and Susanna Walker nobly read and commented on the entire manuscript, resulting in many more apposite examples, much greater clarity and the removal of a variety of errors and infelicities. Raj Aggarwal, Jonathan Benn, Susan Burnett, Nick Sevdalis and Jonny West provided specialist input to specific chapters. Most academic authors suffer from what a friend of mine called the benign neglect of academic editors; in complete contrast, Mary Banks has encouraged me throughout to write the book I wanted to write.

The book could also never have been written without the support and assistance of a number of people. Ara Darzi saw the potential of a unit dedicated to patient safety set within a department of surgery and has supported my work throughout my time in his department. My colleagues in the department and in the Imperial Centre for Patient Safety and Service Quality have been patient and tolerant of my immersion in this project. As every researcher knows, the time-consuming treadmill of searching for funding is a constant distraction from actually doing useful research. I amparticularly grateful therefore to Sally Davies at the National Institute of Health Research and to Vin McCloughlin at the Health Foundation for their support over the years and for providing the stable funding environment in which our research has flourished and which has enabled this book to be written.

The incomparable P.G. Wodehouse dedicated one of his books to his daughter Leonora (queen of her species), without whose never-failing sympathy and encouragement, as he said, it would have been finished in half the time. I must thank my wife Angela for her sympathy and patience and for her encouraging remarks after bravely reading Chapter 1. Everything else I might thank her for is expressed in the dedication.

SECTION ONE

The Evolution of Patient Safety

CHAPTER 1

Medical harm: a brief history

Over the last ten years there has been a deluge of statistics on medical error and harm to patients, a series of truly tragic cases of health care failure and a growing number of major government and professional reports on the need to make healthcare safer. There is now widespread acceptance and awareness of the problem of medical harm and a determination, in some quarters at least, to tackle it. It seems that we are only now waking up to the full scale of medical error and harm to patients. Yet, awareness of medical harm and efforts to reduce it are as old as medicine itself, dating back to Hippocrates classic dictum to ‘abstain from harming or wronging any man’.

The cure can be worse than the disease

Medicine has always been an inherently risky enterprise, the hopes of benefit and cure always linked to the possibility of harm. The word ‘pharmakos’ means both remedy and poison; the words ‘kill’ and ‘cure’ were apparently closely linked in ancient Greece (Porter, 1999). Throughout medical history there are instances of cures that proved worse than the disease, of terrible suffering inflicted on hapless patients in the name of medicine, and of well intentioned though deeply misguided interventions that did more harm than good. Think, for example, of the application of mercury and arsenic as medicines, the heroic bleeding cures of Benjamin Rush, the widespread use of lobotomy in the 1940s and the thalidomide disasters of the 1960s (Sharpe and Faden, 1998). A history of medicine as harm, rather than benefit, could easily be written; a one-sided, incomplete history to be sure, but a feasible proposition nonetheless.

Looking back with all the smugness and wisdom of hindsight, many of these so-called cures now seem to be absurd, even cruel. In all probability though, the doctors who inflicted these cures on their patients were intelligent, altruistic, committed physicians whose intention was to relieve suffering. The possibility of harm is inherent to the practice of medicine, especially at the frontiers of knowledge and experience. We might think that the advances of modern medicine mean that medical harm is now of only historical interest. However, for all its genuine and wonderful achievements, modern medicine too has the potential for considerable harm, perhaps even greater harm than in the past. As Chantler (1999) has observed, medicine used to be simple, ineffective and relatively safe; now it is complex, effective and potentially dangerous. New innovations bring new risks, greater power brings greater probability of harm and new technology offers new possibilities for unforeseen outcomes and lethal hazards. The hazards associated with the delivery of simple, well understood healthcare, of course remain. Consider, for example, the routine use of non-sterile injections in many developing countries. Before turning to the hazards of modern medicine however, we will briefly review some important antecedents of our current concern with the safety of healthcare.

Heroic medicine and natural healing

The phrase ‘First do no harm’, a later twist on the original Hippocratic wording, can be traced to an 1849 treatise ‘Physician and patient’ by Worthington Hooker, who in turn attributed it to an earlier source (Sharpe and Faden, 1998). The background to this injunction, and its use at that point in the development of Western medicine, lay in a reaction to the ‘heroic medicine’ of the early 19th century.