Better and safer surgical care - Surgeons

Better and safer surgical careVictorian Audit of Surgical Mortality-Advancement in the Surgical Safety Frontier

February 2020

Vision: Outstanding healthcare for all Victorians. Always.

Our purpose: To enable all health services to deliver safe, high-quality care and experiences for patients, carers and staff.

Our values: Challenge the norm; Accept nothing less than excellence; Tell it like it is; One team; Bring your whole self

Our aim: To improve health care across Victoria so it is safer, more effective & person-centred by 30th June 2023

ImprovementMonitoring

and Assurance

LeadershipPartnership

and Planning

How will do this?

Strategic approach to quality management

Better and safer surgical care

SCV Quality Management System

Safer Care Victoria - High Level Structure

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Chief Executive Officer

Euan Wallace

Deputy CEO / Chief Nurse and Midwifery

Officer

Ann Maree Keenan

Director - Strategy and Operations

Partner

Robyn Hudson

Director –Improvement Partner

Nicole Brady

Director - System Safety Partner

Helen Rizzoli

Director - Centre of Patient Safety and

Experience

Louise McKinlay

Director - Centres of Clinical Excellence

Rebecca Power

Executive Assistant

Safer Care Victoria - Centre of Patient Safety and Experience Overview

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Director

Centre of

Patient Safety and Experience

Secretariat Clinical Councils and Voluntary Assisted Dying

Patient Experience and Response

Patient Safety Review

Safer Care Victoria - System Safety Partner Overview

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Director

System Safety Partner

System PerformanceSector Development

and CapabilityQuality & Safety

Analytics

Sentinel Event Report 2018/19

Category of sentinel events notified

2018–19

Of the 121 sentinel events notified in 2018–19, 86 (71 %) resulted in death

of the patient..

More consumers on RCA review panels, representing the patient and family voice (33%, up from 17% in 2017-18)

More external experts on RCA panels bringing an independent viewpoint (85% up from 80% in 2017-18)

More people trained in RCA review methods (662, up from 150 in 2017-18)

More recommendations made to improve systems of care (603, up from 466 in 2017-18)

More health services have reported on their progress in implementing improvement (recommendations) arising from RCA reviews (53%, up from 35% in 2017-18 and 3% in 2016-17)

Category 10–11

11–12

12–13

13–14

14–15

15–16

16–17

17–18

18-19

1 Procedures involving the wrong patient or body part resulting in death or major permanent loss of function

1 1 0 0 0 0 1 1 1

2 Suicide of a patient in an inpatient unit 9 8 9 8 4 7 7 7 5

3 Retained (un-retrieved) instruments or other material after surgery requiring re-operation or further surgical procedure

5 7 6 6 6 7 7 12 10

4 Intravascular gas embolism resulting in death or neurological damage

1 0 0 1 0 1 2 0 1

5 Haemolytic blood transfusion reaction resulting from incompatibility

1 0 0 0 0 0 0 2 0

6 Medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs

2 4 1 3 7 1 3 2 5

7 Maternal death associated with pregnancy, birth and the puerperium

2 0 1 3 2 0 3 0 0

8 Infant discharged to the wrong family 0 0 0 0 0 0 0 0 0

9 Other catastrophic: ISR1 37 21 17 33 23 31 49 98 99

Total 58 41 34 54 42 47 72 122 121

Breakdown of Category 9 (Vic Only) 2018/19

38

19

17

8

6

5

2 4

Clinical process/procedure

Deteriorating patient

Falls

Behaviour

Medication/intravenous fluids

Clinical administration

Nutrition

Medical device/equipment

Released revised Sentinel Event Criteria - in effect since July 2019

Revised the Incident Management Policy – now known as the Adverse Patient Safety Event Policy (August 2019)

Released guidance pertaining to Victoria’s ‘other’ category (was cat 9 now cat 11)

Year ahead:

Releasing new tools and factsheets to assist with reviews

Developed new training products in different methods

Our Work at SCV 2019/20

1. Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death

2. Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death

3. Wrong surgical or other procedure performed on a patient resulting in serious harm or death

4. Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death

5. Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death

6. Suspected suicide of a patient in an acute psychiatric ward

7. Medication error resulting in serious harm or death

8. Use of physical or mechanical restraint resulting in serious harm or death

9. Discharge or release of an infant or child to an unauthorised person

10. Use of an incorrectly positioned oro- or naso-gastric tube resulting in serious harm or death

New sentinel event categories from 1 July 2019

Aim:

To identify the extent of patient harm relating to:

• Anticoagulation Therapies

• Bowel perforations from colonoscopies

Method:

• Identify and collate relevant data.

• Establish partnerships with sector groups to guide the projects and assist with data

interpretation.

Intended Outcome:

• Produce a scoping report that identifies high level patterns and/or themes from the data. This

will guide future work in this space within SCV and the sector.

Complications vs Harm? SCV Scoping Projects:

Sharing of protected information for quality and safety purpose

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• monitoring and review of quality and safety of health services

and associated risk

• reporting to the Secretary or a

quality and safety body about:

– performance of health service

– risk to an individual or community associated with performance of health service

• incident and performance reporting

• incident response, including case review.

Just and Learning Culture

Mistakes result from bad systems- not bad people

Every system is perfectly designed to deliver the results it gets

Just culture

Trust, learning and accountability

People are not punished for actions, omissions or decisions taken by them which are in line with their experience and training,

but gross negligence, wilful violations and destructive acts are not tolerated.

“…some prominent leaders began to

question the singular embrace of the

‘no blame’ paradigm … describing the

need for a more aggressive approach

to poorly performing practitioners”

Wachter & Pronovost in NEJM 2009

“…increasing disquiet at how the

importance of individual conduct,

performance and responsibility was written

out of the safety story. [We now] need to

take seriously the performance and behaviours of individuals”

Shoiania & Dixon-Woods in BMJ 2009

Implications for review

• Hunting for a broken component

• Looking for a root cause

• Looking for failures, inadequacies, poor decision

making, judgement errors etc

• Not looking at interactions

Not to assign blame to any individual

To identify how factors across the system combine to create accidents and incidents

Goal

Common flaws

Principles to help improve surgical safety frontier

1. Keep focus on learning2. Manage your bias3. Focus on system

improvement 4. Use a just culture lens

Questions