Dr Nicola Yuen - Bendigo Health - When it all goes Terribly Wrong - How to Keep Patients Safe in the Hospital System

Keeping patients safe in the hospital setting

Is “first do no harm” even possible?

Dr Nicola YuenDeputy Chief Medical Officer /

Director of Obs & Gyn, Bendigo Health

Introduction

● “If health care was an airline, only dedicated risk takers, thrill seekers, and those tired of living would fly on it.”

Dr. Charles Vincent, Patient Safety, 2005

How do we raise the profile of harm such that reducing it becomes an integral part of a hospital’s behaviour??

Scenario● Monday morning…..

WhatshallIdo?

● Get the file● Speak to the VMO● Speak to Midwife● Speak to Complaints officer

Themesofpatientharm

● Insidious failures sometimes known – right people weren’t aware

● Right people were aware but didn’t take the right action

● Catastrophic failures● Poor management / no leadership● Frequent offenders

Methodsofuncoveringharm

● A catastrophic event too terrible to ignore occurs● “Whistleblowing”● Persistent and motivated staff or patients ● Media

● ……..or the hospital discovers it!

Barrierstoidentifyingpatientharm

● 1. Culture within the hospital is damaged● 2. Hospital management structures inadequate to

manage● 3. Hospitals can rationalise adverse events to

themselves● 4. Performance management is hard● 5. Process of external review is difficult and costly

Sohowdoweimprove● 1. Change the culture

● 2. Create robust clinical governance

● 3. Learn from our mistakes

Changinghospitalculture

CreatingClinicalGovernance

● Clinical governance in hospitals – process by which we (managers / clinicians / staff) share responsibility and accountability for patient care by continuously improving, minimising risks and fostering an environment of excellent care

(RCH Clinical Governance Unit)

CornerstonesofclinicalgovernanceClinical Governance Framework

Safety

Quality Maintenan

ce and Improvem

ent

Professional and

Organisational

Accountability

Culture and

Learning

LearnfromourmistakesLearning

Leadership

decisions

Performance

Response to

Incidents

Letsrevisitourscenario● 1. Incident notified● 2. Significance recognised● 3. Investigation highlights both system and individual

errors● 4. Quality improvements implemented● 5. Performance management ● 6. Learn – audit, educate and disseminate the lessons

learned

Whatroledomedicalmanagershave?

● Hospital inquiries through the early 2000s focussed on issues with trust, hospital culture, lack of clinical governance and poor clinical performance

● Responsibility now is to build a listening responsive culture with clear clinical governance

Thefutureofmedicalmanagers

● Clinicians as managers refocus the efforts of the organisation back on to the patients

● Organisationally “multi-lingual”

● “the fewer the resources, the greater the management challenge”

Sowheretofromhere?

● 1. We need to make minimising patient harm a priority for clinicians

● 2. We need to be more open and learn ● 3. Focus on reducing near misses● 4. Build a “responsive” system with whole-of-hospital

accountability