Charles Vincent - Somerville College

Understanding why things go wrongSurgical equipment checks Chain of events120100 Complexity and contributory factors The importance of cumulative minor errorsand deviations Tackling safety on many levels% Checked806040200InstrumentsOperationspecificDiathermySuctionYESNOResults: task completionDistractions in the ORPre-op Intra-op Post-opSurg Urol Surg Urol Surg UrolInterruptions: 13 events/procedure (56min)Mean frequency of door opening during operations as aproportion of OP stage durationEquip 56% 61% 82% 91% 89% 95%Comm 61% 71% 55% 57% 90% 84%Patient 90% 94% 93% 93% 97% 92%Frequency per minute10.750.50.250OP1 OP2 OP3Stage of operationI Reliability of ward careImproving team performance (1) How well do you understand the goals of carefor this patient today? (2) How well do you understand what work needsto be accomplished to get this patient to the nextlevel of care? Less than 10% of nurses or doctors could answerthese questionsPronovost et al, 20034

8 Evaluation SitesPAHO IToronto, CanadaEUROLondon, UKEMROAmman, JordanPAHO IISeattle, USAWPRO IManila, PhilippinesAFROIfakara, TanzaniaSEARONew Delhi, IndiaWPRO IIAuckland, NZGlobal results ProcessGlobal results OutcomeChecklist is not just a checklistLooking ahead Clarification of roles and responsibilities– Ward care– Handover– Operating theatre Softening the hierarchy Towards a shared mental model Anticipation of problems Broadening the scope of safety Safety in specific clinical domains The science of safety Creation of centres6

Explore dimensions of harm in each settingOrganisational change in healthcare Hospital acquired syndromes in care of the elderly– Dehydration– Malnutrition– Delirium– Depression– Pressure sores– Incontinence A focus on systems Local ownership and engagement Encouraging local adaptation of the intervention Creating a collaborative culture Time and resourcesPronovost et al, 2008Further InformationClinical Safety Research Unitwww.csru.org.ukCentre for Patient Safety & Service Qualitywww.cpssq.org7