the lessons of bristol (models for the future)
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The Lessons of Bristol (Models for the Future). Associate Professor Stephen Bolsin Department of Perioperative Medicine The Geelong Hospital Barwon Health. The Lessons of Bristol. Other examples Manitoba Paediatric Cardiac Surgery Inquest (Canada) Dr Harold Shipman Inquiry (UK) - PowerPoint PPT PresentationTRANSCRIPT
The Lessons of Bristol(Models for the Future)
Associate Professor Stephen Bolsin
Department of Perioperative Medicine
The Geelong Hospital
Barwon Health
The Lessons of Bristol
• Other examples• Manitoba Paediatric Cardiac Surgery Inquest (Canada)• Dr Harold Shipman Inquiry (UK)• Dr Michael Swango (USA)• Bristol Royal Infirmary Inquiry (UK)• 40 deaths in private clinic 2000 (France)• Dr Reimers charged with manslaughter 2001 (Aus)
Safety in Health Care
Stimulus to change
• 1995 ‘Quality in Australian healthcare study’
• 1999 ‘To err is human’ Institute of Medicine, USA
• 44-98K patients die through error in US hospitals
• 3-6K patients die through error in Australian care
• Bristol Inquiry 2001 “could be happening now in NHS”
• Public demand for change
Safety in Health CareQuality in Australian Health Care Study 1992
Wilson RMcL, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471.
• 16.6% of admissions had iatrogenic injury• 14,000 admissions to 28 hospitals (NSW & SA)• Extrapolate <230,00 preventable adverse events• Extrapolate <14,000 preventable deaths
Safety in Health CareCauses of Adverse Events (50% preventable)
34.6% complication/failure of technical performance
15.8% decision/action failure
11.8% failure to arrange procedure/investigate/consult
10.9% lack of care/attentionAn analysis of the causes of adverse events from theQuality in Australian Health Care Study
Ross McL Wilson, Bernadette T Harrison, Robert W Gibberd and John D Hamilton
MJA 1999; 170: 411-415
Safety in Health Care
Limited adverse occurrence screening:
using medical record review to reduce
hospital adverse patient events
Alan M Wolff
MJA 1996; 164: 458
Safety in Health Care
Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program
Alan M Wolff, Jo Bourke, Ian A Campbell and David W Leembruggen
MJA 2001; 174: 621-625
Safety in Health Care Wolff M A. MJA 1996; 164: 458
General patient outcome criteria used for screening
of medical records – Death.
– Return to operating theatre within 7 days.
– Transfer from general ward to intensive care unit.
– Unplanned readmission within 28 days of discharge.
– Cardiac arrest.
– Transfer to another acute-care facility.
– Length of stay greater than 35 days (reduced to 21 days in 1993-1994).
– Theatre booking cancelled.
Safety in Health CareWolff M A. MJA 1996; 164: 458
15,912 patients screened
1,465 (9.21%) screened positive for criteria
155 (0.97%) screened positive for AO
110 major 45 minor
88 (56.8%) cases minor or not preventable
67 recommendations to patient care committee
66 recommendations for changes in policy
Changes in policy clinical & administrative
Safety in Health Care
Wolff M A. MJA 1996; 164: 458• Reasonable rate of detection on screening by clerks • Reasonable rate of confirmation by clinicians• LAOS will detect circa 50% of adverse events• Requires 10% review of medical records• Fast & accurate• Costs <0.1% of total hospital budget • Reduction in adverse events by >50% in 3 years
Safety in Health Care
Wolff AM et al. MJA 2001; 174: 621-625
49,834 inpatients screened
20,050 EMD patients screened
Inpatient record review
EMD record review
Clinical incident reporting
GP reporting
Safety in Health Care
Inpatient adverse events down from 1.35% - 0.74%
(Reduction from 69-49 events in 8 years p<0.001)
EMD adverse events decreased from 3.26% - 0.48%
(Reduction from 84-12 events in 8 quarters p<0.001)
“Adverse events can be detected...”
“...and their frequency reduced using…detection methods and clinical improvement strategies...
Safety in Health CareCauses of Adverse Events (50% preventable)
34.6% complication/failure of technical performance
15.8% decision/action failure
11.8% failure to arrange procedure/investigate/consult
10.9% lack of care/attentionAn analysis of the causes of adverse events from theQuality in Australian Health Care Study
Ross McL Wilson, Bernadette T Harrison, Robert W Gibberd and John D Hamilton
MJA 1999; 170: 411-415
ANZCA Personal Professional Monitoring Project
• Pietroni 1993 Ann RCS;75:200-2.
• de Leval et al. 1994 J Thorac Cardiovasc Surg;107:914.
• Kestin 1995 BJA;75:805-9.
• Ellis 1995 BJA;75:673-4.
• Day & Bolsin 1998 Short Practice of Anaesthesia.
• Bolsin 2000 Int J Qual Health Care;12:367-369.
• Bolsin & Colson Int J Qual Health Care;12:433-8.
• Bolsin 2001 Aust Health Review;24:1-4.
ANZCA Personal Professional Monitoring Project
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ANZCA Personal Professional Monitoring Project
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ANZCA Personal Professional Monitoring Project
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ANZCA Personal Professional Monitoring Project
Graph 4
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ANZCA Personal Professional Monitoring Project
• Recruits – 1st year Anaesthetic Registrars– Supervisors of Training
• Collects Electronically– Log Book data on procedures– Data on procedural performance– Data on adverse incidents
ANZCA Personal Professional Monitoring Project
• Sponsors– ANZCA (Australian & New Zealand College of
Anaesthetists)– United Medical Protection– PALM Corporation of Australasia– VMIA– Sync International
ANZCA Personal Professional Monitoring Project
Procedures monitored• IV line insertion• IA line insertion• CVP line insertion• Epidural insertion• Spinal anaesthetic• Brachial Plexus block• Other blocks
ANZCA Personal Professional Monitoring Project
• PALM III handheld computers
• Personal log book
• Customised synchronising programmes
• Electronic data collection
• Electronic data retrieval
• Secure electronic data transmission
• Remote Analysis
• Secure return of analysed data
ANZCA Personal Professional Monitoring Project
• Data collection in <1 minute
• Cultural change has been achieved
• Enthusiasm is palpable
• Other Specialities are interested
• Other Professions are interested
• Registrars are Specialists of the Future
• Data from any procedures collectable
ANZCA Personal Professional Monitoring Project
ANZCA Personal Professional Monitoring Project
ANZCA Personal Professional Monitoring Project
ANZCA Personal Professional Monitoring Project
ANZCA Personal Professional Monitoring Project
ANZCA Personal Professional Monitoring Project
ANZCA Personal Professional Monitoring Project
ANZCA Personal Professional Monitoring Project
Palm
Desktop
SecureServer
Anaesth.College
APSF
ANZCA Personal Professional Monitoring Project
Phase 1 Project
• Six 1st or 2nd year registrars recruited
• 3 Centres in Australia & New Zealand
• 4-7 month data collection
• 1690 Cases collected
• All collected data analysed
• Some data lost (batteries & breakages)
ANZCA Personal Professional Monitoring Project
Phase 1 Project
• Supervision – 62% level 1; 22% level 2
• 27% out of hours
• 11% remote locations
• Operative Speciality
• 480 procedures logged for Cusum analysis
ANZCA Personal Professional Monitoring Project
Phase 1 Project
• 42 critical incidents
• 2.5% of total anaesthetics logged
• 19 uneventful; 8 minor;14 major; 1 death
• 64% “near miss” reporting
• cf 50% event reporting by LAOS
• 21 airway respy events; 17 cardiovascular
ANZCA Personal Professional Monitoring Project
Phase 2 Project
• 715 anaesthetics recorded
• 17 critical incidents
• 2.4% of total anaesthetics logged
• 7 uneventful; 8 minor;2 major
• 88% “near miss” reporting
• 7 airway; 4 procedure; 2 cardiovascular
ANZCA Personal Professional Monitoring Project
• Relatively objective.• Easy and quick to collect.• Provides early feedback.• Provokes specific action early.• Consistent with the “continuing quality
improvement” paradigm.• Allows for ongoing, self directed learning• Phase 2 better than Phase 1
ANZCA Personal Professional Monitoring Project
“The Future Now”• Personal Professional Monitoring• Real Time Prospective Reporting• Numerator Data & Denominator Data• “Near Miss” Reporting• Critical Incident Analysis• Targeted Incident Reporting• Immediate Feedback of generic data• Policy & Procedural change as a result
ANZCA Personal Professional Monitoring Project
The Vision• Reduction in Adverse Events• Elimination of attributable Adverse Events• Improved Health Care Practice• Reduced Health Care Costs (Au$4-6 billion)• Improved Patient Outcomes• Reduced Legal Costs• Safest Hospital status
ANZCA Personal Professional Monitoring Project
• www.ppm.com.au– Articles on CUSUM
– Product details
– Program tour
• www.syncint.com– Look under what’s
new
Professional Monitoring & Cultural Change
A/Prof Stephen Bolsin, Dr Mark Colson,
Dr Peter Stow, Dr Peter Tolley, Mr Morteza Mohajeri, Mr James Kenny, Dr Rory Wolff
Depts Perioperative Medicine, Cardiac Surgery & ICU
The Geelong Hospital
Barwon Health
Dept Epidemiology & Preventive Medicine
Monash University
Complication - Second 500
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Professional Monitoring & Cultural Change
Inexplicable change in performance
Complication - Third 500
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Professional Monitoring & Cultural Change
Protocol Changes
New Surgeon Xmas Holidays
Review Meeting
Professional Monitoring & Cultural Change
• Overall bleeding rate 5.5%
• Important variables on univariate analysis– Emergency category– Renal failure (Pre-op creatinine >120mol/L) – Cardiopulmonary bypass time (10% : 10 min)– Surgeon
Complication - Third 500
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Professional Monitoring & Cultural Change
Review MeetingProtocol Changes
Xmas holidays
New Staff Changed Performance
Professional Monitoring & Cultural Change
• Further analysis required
• Renal failure implicated
• Bypass time implicated
• Emergency surgery implicated
• Surgeon in part explanatory
• Surgeon effect remediable
• Decrements in performance explicable
• Increments in performance inexplicable
Professional Monitoring & Cultural Change
• We are being expected to do better
• We could do better
• We should do better
• Our patients would want us to do better
• Our patients would benefit
• We would benefit
• “All Win” Medical Management