Aprendendo com Erros

the National Health Service in the United Kingdom was one of the first Healthcare Systems in the world to give priority to patient safety the work done in the UK over the last few years has involved taking account of the things that go wrong in health care the frequency of medical error and unsafe care is much higher than we've realized in the past something like one in every 10 patients admitted to hospital suffer from some form of medical error it may not always lead to Serious harm but in some cases sadly it leads to Major disability

and even death one of the incidents we've examined in depth is the phenomenon of intrathecal injection error this is where a drug intended for use intravenously is given instead into the spine mistakenly the patient then experiences paralysis and even death when we've analyzed these incidents in depth we've spotted all sorts of errors and weaknesses in the system which provoke unsafe care to be given by analyzing these and by learning from them we've tried to work out the ways in which this error can be prevented in the future there are around 50 recorded incidents around the

world of intrathecal injection error many more may not even have been recorded from the incidents we're aware of so far we know that they often occur in similar circumstances to different people at different times and even in different places experts call this situation an error trap there's a common cause and probably a common solution with this film the world Alliance for patient safety is making the experience of the United Kingdom available worldwide we hope that by studying this scenario and discussing it afterwards you'll be able to see the many ways in which unsafe systems can

provoke unsafe care by generalizing the experience of this particular incident we hope that you'll be able to see the ways in which strengthening systems play a role in reducing the impact of error this can help make Health Care even safer in the future of Dr Livingston yeah telephone oh thanks Sam excuse me Duncan hello yeah it's ramesha Pharmacy here yes it's about Mrs Jane Hughes me to attract's sake you sent down I've only sent Harvin Kristen up I was wondering if um that'd be a mistake about that Mrs Hughes is having both her procedures on

the same day she's got a big work commitment in a couple of days yes the treatment should go ahead he signed the prescription yes I see very irregular I assume that you'll be taking the full responsibility yes okay then look I'll uh prepare it for this afternoon I'd like you to meet Dr Campbell he's just joined us and he's going to be working with me over the next couple of weeks I have to say Duncan you're going to be giving us some much needed support glad to hear it hello sister nice to meet you welcome

to the unit thanks very much oh by the way Anne Mrs Hughes will already be on your list this morning for her IV which is also having her intrathecal this afternoon she's got a big meeting at work in a few days time so we're going to try and fit her in for both procedures today work she's only just started she's taking it easy only a couple of days to begin with right so Duncan your papers and NTN number should be through in a day or so but meanwhile welcome aboard thanks very much ah it's my

big problem I'll take you through here I'll see you both later okay Dr Livingston before you go I uh just wanted to be clear about the amount of we got he'll take on virtually anything I would if he's unsure about anything then I'm always here to help so he's familiar with the it rules well I would certainly expect so he's very senior and he can do just about anything I can but Fiona he's not on the it register yet is he no but I'm seeing Dr Monroe about that later and we'll sort it out then

oh Simon I wanted a word so he's fine with any of our procedures well he's here on the personal recommendation of Dr Monroe's sister so as far as I'm concerned if Dr Monroe thinks he's competent and prepared to go along with that now he'll be acting as the specialist registrar and I'm hoping that you and your staff will give him every assistant of course we will right but Jane Hughes is intrathecal that will still be under your care won't it yes I'll be there hi Abby it's Jane Hughes here I'm Abby I'm gonna be late

I'm stuck Jane Hughes just phoned apparently there's been a really nasty accident on the motorway and she's caught in the tail back great yeah she said she's going to be quite late at least two hours what a day to be late look Abby I'll be off shift by the time she gets here I've got to leave a bit early for a dentist appointment I'll put everything in the notes but I'm going to miss the Handover so can you make sure that sister Roberts knows what's happening of course I'll get the looks ready for her all

right darling are you okay good boy being a really good boy we'll be there soon there as soon as I possibly can do try to calm down it should only take me half an hour at the most I'll see you as soon as possible is everything okay not really sister no actually that was my mother on the phone my father's had a coronary I've got to get over to the general oh I'm so sorry yes obviously you must go thank you look Dr Campbell will cover for me could you show him around and take him

through the notes when you get a chance uh yeah I mean I haven't had a chance to see the notes myself yet but I'll do what I can I can I'm sure we'll manage I hope he's okay thanks I'll call in later okay yeah can you cover for me this afternoon sure I'm sorry about the late notice it's my father he's had an MI and I want to be with him oh my God I'm sorry of course no problem thank you I've asked sister Roberts to go over a few things with you I'm sure between

you you'll manage fine sure good luck thank you foreign I've got to get over to the general oh I'm sorry to hear that okay yeah excuse me I'm Dr Campbell covering for Dr Livingston today hello Dr Campbell hi there have you seen her sister anywhere sister Roberts yeah there she is down there by the nurses station sister Roberts thanks baby sister Roberts I'm Dr Campbell covering for both of Livingston today um I understand she's arranged for an essay to give us a hand this afternoon Dr Simon Robinson is he here yet no not yet Abby

issues arrived yet please no she's just called in she's about 10 minutes away she she's one of mine about the Atlanta Pharmacy for the chemo thanks very much see you later okay when Mrs Hughes arrives can we make sure that bay Eight's ready for her please yes of course Helen thank you oh yeah come on hi I'm just coming back from Steven's unit I'm covering for Dr Livingston I've come to pick up the chemotherapy for Mrs Jane Hughes entity called Methotrexate she's under Dr Monroe all right I don't know we've met have we Dr Campbell

I'm Charlotte Green and she'll be performing the procedure right I'll just check the register just procedure um I don't seem to have you down well there should have been sorted out with Dr Monroe by name and I think that Dr Livingston spoke to Mr Shah earlier on okay then sorry about this take a seat let's have a look on the database Campbell Duncan Campbell I mean it should be there there's no questions I'm sorry I'm just at a crucial time that's all oh yes there you are sorry about this hello Pharmacy yes yes that's right

and what's the patient's name again not sure that's fine be ready by four this afternoon okay great bye um it seems he's only just put you on the list um now you're a patient would that be a right I'll just check this is ready for you definitely our doctor Methotrexate two milligrams and two mils and being sorry doctor excuse me for a moment when I take this hello Pharmacy yes it is but I'm focused on lunch at the moment can I take a message and what station is that fine bye now where were we Jane

Hughes Hospital number three two six seven nine eight zero date of birth 26 12 74 batch number bx437 two nine four excellent uh now if you could just sign here and we've got capitals here with pleasure bye bye sweetie hi Jane hi oh you must have had a nightmare though I'm so sorry I feel old don't worry gosh that's me grow yeah he's into everything where are we today Abby well I'm not quite sure what's happening today they're having a few problems but I'm pretty sure we're in Bay eight yes it's this one look can

I take you back oh thanks Mrs Hughes arrived yet yes she is just settling in there great look would you check this Methotrexate with me please thanks a lot changes can I borrow your pen okay I've left my own Pharmacy there we go thanks a lot look would you put this in the fridge for me while I go and deal with this thanks a lot hi sister hi Simon it's Mrs Hughes here yep yeah she's just checking in now thanks for helping out I've left our notes on the side and I'll be with you in

a minute no problem so has George used to be hot and bothered actually he had a terrible tattoo in the car on the way here to bumper for hours it was awful anyway he's stepping down with his dad now so oh hi Simon I'm gonna see you here very often I've been on nights just come off oh oh could you get James Waterman how's that bad for me please so what can I do for you Dr Livingston asked me to give you a hand this afternoon it seems like she's got her hands full oh great

sorry um Mrs Hughes isn't it yes I'm Dr Robinson how are you feeling pretty awful actually I've been stuck in the car for hours I'm so sorry to hold you all up oh no problem no problem hi it's Mrs Hughes I'm Dr Campbell coming for Dr Livingston this afternoon hi Dr Campbell I heard about her father it's awful will he be all right I'm sure he's in very capable hands ah you must be Dr Robinson thanks very much for helping us out at such short notice no worries happy to help no uh Mrs Hughes you

understand what treatment you'll be having this afternoon yes I do right let's have a look at Mrs Hugh's blood results then shall we that all looks fine consent form yes observation's all right yeah right would you check the response can you please right it's Mrs Gene Hughes Hospital number 326-7980 date of birth 26 1274. good lovely perfect let's just get on with this great look listen before you do that would you just um check the local with me then I'll prep the skin sure look I've asked Dr Campbell twice today to call me when you

pass my message please yeah no you will feel just a little bit of pressure here we are wonderful that's great anything important I'm not sure taking a message there you go right so uh who was it someone from admin that's the third time today all right I'm ready for the chemo now Simon I'm sorry would you mind going and picking up from the from the fridge I think we've lost completely now it certainly seems like I think there's a problem on the wall I'll find out what's happening thanks very much something all right Mrs Hughes

won't be much longer now here we are I'm afraid Abby's going to be a while yeah I've Just Seen Her rushing around look we can't afford to waste any more time you'll just have to check it with me is that okay okay fine Hospital number 326-7980 dfb 26 1274 yeah expiry date 080903 everything okay Simon Dr Campbell yeah everything's fine fine I understand you've got a bit of a problem on the ward yes uh I'm sorry staff now shouldn't be too much longer actually we're nearly finished you know tell me it's my next it patient

arrived here yeah he's in the waiting room I have explained we're running mate uh can you check his blood results thanks ignore it just ignore it you will thank Dr Livingston for me won't you it's such a help you fitting me in like this of course I will it's not a problem thanks is that okay okay fine Christine two milligrams in two mils right thank you okay that's it it's got a plaster brilliant sorry to hold you up you kind of finished already yeah up here I've got the methotrexate so what have you given her

and someone called Dr Monroe please the film you've just seen provides a shocking example of how a series of Errors can lead to catastrophic harm to a patient the first question you might like to ask is who was responsible for this tragic outcome the most obvious answer may be Dr Campbell he mistakenly injected vincristine into the patient's spine however I want you to consider a far more critical question why did Dr Campbell find himself in such a position sitting in front of a patient with an open spinal needle in their back having been handed the

incorrect and potentially lethal drug in reality Dr Campbell's error was the final act in a chain of events Each of which had it been identified at the time May well have prevented this tragic outcome it's therefore important to carefully review cases such as this as much as possible we need to do this without blaming the individuals involved that's not to say that individuals should not be held accountable for their actions however although apportioning blame may be emotionally satisfying it's likely to drive problems underground and impede an honest and far-reaching understanding of the risks we need

to address these risks to ensure the safe care of future patients let's return to the film and identify some of the factors that played a part in this era in most Healthcare settings worldwide there are strict Frameworks in place regulating the use of chemotherapy drugs like van Christine these include prohibitions against storing such drugs in a fridge with other medicines and giving them in conjunction with other therapies in many countries there are also regulations specifying that a registered chemotherapy nurse must be present during the procedure and that the treatment must be given in a special

room or Bay these types of Frameworks and regulations are known as standard operating procedures or guidelines these standard operating procedures and guidelines apply widely and are not specific to the use of drugs like vincristine for example well-known are the advanced Trauma Life Support guidelines from the American College of Surgeons and the World Health organization's pain ladder for safe and effective administration of opiate analgesia in the film we've just seen you should clearly know that the standard operating procedures and guidelines were not adhered to yes it's about Mrs Jane Hughes meet for black sake you sent

down you've already got her down for her IV this morning and I've only sent her in Christina the method tracks age should not have been dispensed on the same day as Vin Christine a mix-up of these two drugs could lead to fatal consequences and a protocol was in place to prevent this had it been adhered to the error may have been avoided okay then look I'll prepare it for this afternoon factors that may have led to the pharmacist breaking the protocol are many and varied they include the pressure of work and the hierarchical management structure

which does not encourage constructive questioning of the doctor in charge Methotrexate Dr Campbell should not have been allowed to administer chemotherapy down he was not confirmed as having the skills to do this despite this the nurse was persuaded to allow him to practice on the ward and the pharmacist allowed him to pick up the prescription a system was in place but not adhered to here we are Dr Methotrexate two milligrams sadly in many areas of healthcare when these procedures are in place their purpose is often misunderstood and they may even be treated with contempt lack

of organizational leadership poor communication high workloads and inadequate Education and Training all contribute to the lack of adherence actually standard operating procedures and guidelines can be a great protection against error their objective is to make patients and practitioners as safe as possible each and every time that a procedure or action is undertaken standard operating procedures do not destroy clinical autonomy or decision making rather they provide an evidence-based agreed framework for protecting patients against error whatever possible they standardize the procedures in place so that everyone understands their role and what is expected of them where standard

operating procedures and guidelines are present they must be adhered to where they're not in place appropriate measures should be taken to establish them we need to make sure we have an organization-wide view of standard operating procedures and guidelines so these essential components of Safe Care do not fall by the wayside we need to see such procedures as the Hallmark of professionalism and good patient care rather than as an enemy when standard operating procedures and guidelines are present we need strong and visible leadership to ensure they are adhered to for your organization ask yourself the following

questions could standard operating procedures and guidelines be put in place to make delivery of care safer our standard operating procedures and guidelines being adhered to and if not which pressures prevent their operation is there a culture of contempt within your organization for standard operating procedures and guidelines we can only really be sure that we're delivering safe care for patients if all the healthcare workers involved have received the right training and are up-to-date a healthcare professional who has not received appropriate training or guidance may feel under alert pressure to just do the job there can be

a lot of pressure to cope with the workload by operating Outsider competence especially for junior staff such staff may not be well placed to judge their own level of competence they may be over or underconfident because of their limited experience this is a potentially dangerous situation where errors can easily occur in the film it was obvious that nobody had a clear understanding of the level of training or experience that a nearly appointed Dr Campbell had Dr Livingston before you go I just wanted to be clear about the amount of clinical work Dr Campbell will actually

be doing how much have we got he'll take on virtually anything I would if he's unsure about anything then I'm always here to help so he's familiar with the I.T rules well I would certainly expect so he's very senior and he can do just about anything I can but Fiona he's not on the it register yet is he no but I'm seeing Dr Monroe about that later and we'll sort it out then sister Lynch in fact Curry this several times with his colleague Dr Livingstone despite this lack of clarity Dr Campbell was left in charge

once Dr Livingston left the ward sister Roberts I'm Dr Campbell covering for both of Livingston today a culture where healthcare workers help each other especially when staffers stretch May inadvertently increase the risk to patients often many staff may not easily recognize the boundaries of their own expertise and experience poorly trained healthcare workers can be a major contributing factor leading to Adverse Events many countries are good at ensuring a certain standard as part of undergraduate training however in many cases the last assessment a healthcare professional faces is at their University or College assessments are not just

about ensuring a certain and sustainable level of skill knowledge or competence they're also a reflection of wider culture of safe and effective practice Education and Training are critical components in the quest to improve patient safety at the very least or healthcare workers must understand the key concepts of patient safety for those already in practice programs must be developed to give them the skill to continue to practice safely most of all Healthcare professionals should know and understand safety procedures in their own local service contacts in other high-risk Industries careful attention is paid to ensuring the ongoing

competence of Frontline staff for example a typical airline pilot would probably have something like a hundred assessments of their competency over the course of their career in some countries doctors have none for your organization ask yourself the following questions how do you know that the colleagues you work with have received the training they need to do their job well do you have a way of assessing colleagues you work with to ensure they're competent do you have a framework in place to ensure induction with local procedures do you know what you should do if you have

concerns about the competence of your colleagues and the safety of their practice would you be supported in raising your concerns and finally how would you know if your Healthcare System allowed an unskilled or untrained Healthcare professional to practice clear communication and effective team working between different healthcare workers from different professional groups is essential for delivering safe care for patients in many countries Healthcare is becoming more and more specialized and clear communication within the multidisciplinary team is vital to ensure there is Clarity of roles and responsibilities procedures and outcomes time and time again research has shown

that ineffective communication and poor team working has been a major cause of an adverse event and heightens the risks to patients Campbell Duncan Campbell I mean it should be there there's no question so definitely running right now there's Mrs Hughes arrived here yes she is just settling in there great look would you check this Methotrexate with me please thanks a lot can I borrow your pen okay I've left my own Pharmacy there we go thanks a lot look you put this in the fridge for me while I go and deal with this thanks a lot

in the film it should be obvious that these two turfs exchangers and communication breakdowns contributed to the error it is not just verbal communication that can be at the heart of serious error these professionals are not working effectively as part of a multi-professional team they're not respecting each other's roles and responsibilities and supporting each other and delivering a common goal the safe and effective care of their patients as you can see without verbal Handover the written note had no context in the midst of a complex and stressful situation important messages that should have been clearly

communicated between staff were lost the lack of effective staff handovers and lack of clarity and individual rules gives opportunities for misunderstandings to arise communication can be aided hugely just by stepping aside into a quiet spot even if only briefly staff need to have mutual respect for each other's role and professionalism they need to be able to respect and value constructive questioning and deal honestly with misunderstandings a hierarchical structure and a culture for junior staff are afraid to speak up and effectively challenge or query the decision-making of senior staff can contribute to poor team working and

the resulting poor communication environmental factors such as stress caused by understaffing and overwork also play A Part an appreciation of the cultural differences is a key skill for successful Communication in our Multicultural world this is particularly important in health care especially when workers and patients may be from different cultural or socioeconomic backgrounds making some of the sensitive aspects of Health difficult to address differences in language customs and conventions and even religion all have the potential to lead to poor communication and misunderstandings some organizations still have a culture where respectful dialogue and inquiry is not encouraged

we need to move away from this to a culture which requires open and honest communication between all players in the healthcare setting Handover and clear documentation need to be actively encouraged and promoted effective teamwork needs to be encouraged for your organization ask yourself the following questions to what extent in your Healthcare setting have you addressed the need to have effective multi-disciplinary communication do staff value or even know about each other's roles can junior staff approach senior staff and make a legitimate inquiry about the safety of a situation and finally do you work well as a

team correct labeling storage and dispensing of medicines is vital to protect the patient against potentially lethal harm medication errors in some Studies have accounted for up to 30 percent of medical errors safety of medication delivery is thus one of the most pressing issues of the patient safety agenda in the film almost everything that could have gone wrong with Jane's medication delivery did go wrong this chain of events started long before she was administered the wrong drug standard operating procedures and guidelines to prevent Vin Christine being stored with the Methotrexate should have been adhered to ah

you must be Dr Robinson thanks very much Dr Robinson and Dr Campbell had never met before they did not have specific training to be checking these drugs it should have been the certified nurse that was involved at this level traditionally healthcare workers have worried mainly about the issues of adverse drug reactions where the patient has been given the right drug but suffers from a side effect a separate area which concerns itself with ensuring the right standard operating procedures and guidelines are being followed and the right dispensing and Delivery Systems are being used is known as

medication safety practice this is an important area which examines Healthcare Systems to try to prevent errors such as that in the film we all know how bad a doctor's handwriting can be yet sometimes the medical notes are the only way that Healthcare professionals have to communicate with each other therefore medical records need to be clear and unambiguous they need to provide an accurate way of conveying important actionable information it is essential that all hospitals clinics and treatment centers have established policies for ensuring medication safety in general whether we are dealing with increasing or not there

are certain principles that you may want to consider for example all drugs must be clearly labeled and labels must be easily visible drugs must be properly checked by the designated person against the patient's medical records and the drug chart and for high-risk treatments like chemotherapy drugs must only be given by nurses and doctors with specialized registered training for your organization ask yourself the following questions our medical notes easily accessible kept regularly up to date and easily legible do your procurement policies ensure consistency of drug purchasing and checking mechanisms to detect potential errors such as lookalike

and sound alike medications and finally do you have systems in place to ensure only those properly trained or able to be involved in the delivery of high-risk drugs of all parties in a healthcare setting patients often have the least input into their care yet much Research indicates that patients can not only enhance the quality of their care but can prevent errors when arriving at the hospital Jane was stressed because of a long car journey through gridlock traffic and probably also because of the trauma of living with cancer and facing more unpleasant procedures nevertheless she was

put at ease by the nurse who asked her how she was feeling and inquired about her family so far so good however once Jane had been escorted to the treatment Bay she was no longer treated as an individual the multi-disciplinary team failed to acknowledge her as someone who could provide valuable input into her own care she was not even asked what she had come for could she have had a card by which her treatment was checked with her as well would that have provided an additional safety barrier Jane might have been able to spot that

the team was proceeding with the intrathecal drug injection before she had been given her intravenous treatment had she been able to point that out what followed might not have happened it was the hospital's responsibility to ensure that Jane's care was safe but involving Jane actively in her care may have prevented the terrible outcome a patient who is familiar with the procedure is a vital resource for any healthcare worker to draw on they may be able to spot discrepancies in the treatment plan and any deviations from standard operating procedures discrepancies in communication or odd drug labeling

patients are often far more insightful than we give them credit adopting a more patient-centered approach trying to look at the situation from the patient's point of view will make patients feel more relaxed more comfortable and lead to more effective consultation and diagnosis it enhances quality and promotes safety it may also save time and money for your organization ask yourself the following questions what happens in your organization to ensure that patients are active Partners in their own treatments how could your organization play a more active role in this challenge and finally could other means of engaging

patients be used such as posters leaflets and patient treatment cards the world Alliance for patient safety believes that we need to understand the nature of these contributing factors we must learn from the errors and harm we unintentionally cause to patients in order to reduce the risks for future patients we need to act on this learning and make improvements throughout our Health Care Systems commitment from governments Hospital management and clinical leaders is vital to achieve this we must also work collaboratively with patients but let me finish with five challenges firstly do you have standard operating procedures

and guidelines in your workplace are they adhered to if not why not could you develop these if they're not already in place secondly does your workplace have a framework in place to ensure healthcare workers are up to date with training and are they safe to practice thirdly do you communicate effectively with your colleagues as part of a multi-disciplinary team fourthly is information about the safe use of drugs accessible to you in your workplace and finally have you engaged your patients in their own care analyzing and understanding errors like this will take us away from a

blame culture and move us to a situation where we can offer safe high quality and sustainable care to our patients not just now but in the future