Human Factors in Patient Safety Error Risk & Safety in Hospital Practice

1. RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Human Factors in Patient Safety Error Risk & Safety in Hospital Practice Eva Doherty, Dara O’Keeffe, Angela O’Dea, Mark Corrigan, Anna Moore, Ruth Little

2. Objectives for Today • Analysis of accident causation and trajectory • Comparison of Aviation and Healthcare – can lessons be applied across industries? • Safety Models and Frameworks • Application to healthcare case studies

3. Case Study – Elaine Bromiley

5. Individual Team Organisation Environment

7. WHO Framework of Sociotechnical Systems (Moray, 2000) Societal, Cultural & Regulatory Influences Team (group) Organisation/management Individual Work Environment/ Equipment Patient

8. SHELL MODEL of Human Factors in Aviation

10. Fishbone Diagram Task & Technology Individual Team Patient Problem / Issue to be explored Work Environment Institutional Context Organisation & Management

11. Swiss Cheese Model. James Reason Inadequate training Failure to follow procedures Faulty equipment Poor decisions Inadequate supervision Poor protocols Unsafe acts

12. Vanessa Anderson

13. Vanessa Anderson • failure to communicate to Dr Little that Vanessa was admitted under his care, • a shortage of neurosurgery registrars on call • neurosurgical fellow was performing registrar duties and was over burdened with work and tired, • Dr Williams who was the senior neurosurgical resident at the time had only worked in the neurosurgery unit for 2 weeks, • Dr Bezyan was an intern on her first day in the neurosurgical unit, • Record taking and clinical notes were either non existent or deficient • Dr Little’s directive after first seeing Vanessa to chart and administer Dilantin was not followed, • Concerns raised by Mrs Anderson regarding side effects of Dilantin were not communicated or further advice sought from Dr Little, • A failure by Dr Ismail to consult Dr Little in regard to increased analgesia, • A failure by medical staff to be aware of general policies which require consultation with the treating Doctor in cases where constraints to the quantity and type of analgesia should have been known, • A failure to conduct neurological examinations as per the set time frames, • The wisdom, albeit for good intentions in regard to privacy, of placing Vanessa in a room furthest away from the Nurses station.

14. Wrong Kidney Removal Case: The review team identified ten principal Contributory Factors 1. An incorrect imaging report from six years earlier had not been identified and corrected. 2. Delays in filing hard copy x-ray reports in the medical records, and lack of reference to an electronic copy. 3. There was no failsafe system to ensure that a patient undergoing removal of a major organ was discussed in a multidisciplinary setting, as the consultant had intended. 4. Patients are regularly admitted outside normal working hours. 5. Radiology is not normally sent to the ward or to theatre. 6. Formal consent is generally taken by surgeons who are not competent to perform the procedure. 7. The person taking consent for a procedure will not normally review imaging. 8. SpR hours and workload, and concomitant lack of planning for cross-cover. 9. The hospital has no site marking policy, or common practice. 10. The operation and planning of the parallel theatre list.