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LEARNING
FROM
FAILURE 1
DR JOHN ROOKSBY
IN THIS LECTURE
Today - two lectures looking at how organisations can investigate
and learn from failure
• Incident reporting
• Accident investigations
Incident reporting:
• It is important to learn from incidents irrespectively of whether
  they caused harm
• Aviation, Healthcare and the Nuclear industry routinely collect
  incident data, but with varying success
• Collecting incident data can be problematic – mainly because
  people don‟t want to be blamed for highlighting incidents
Accidents are the “tip of an iceberg”
• Incidents or “adverse events”
  are far more common, and
  underlie accidents.

Incident reports highlight faults or
report errors and near misses
where there was potential for an
accident.

If incidents are not reported, they
may never be noticed by anyone
other than those involved

What constitutes an incident and
whether it warrants reporting can
be a judgement
                                        http://en.wikipedia.org/wiki/File:Iceberg.jpg
INCIDENT REPORTING
SCHEMES
Incident Reporting Schemes are mechanisms for learning from
errors and failures
Used in many safety critical domains:
• Healthcare, Aviation, Marine, Railways, Nuclear Power, Oil and
  Chemical Production
Increasingly used in complex, business critical environments:
• For example Data Centres
EXAMPLE REPORT - AVIATION
On pre-flight check I loaded the Flight Management Computer (FMC),
with longitude WEST instead of EAST. Somehow the FMC accepted it
(it should have refused it three times). During taxi I noticed that
something was wrong, as I could not see the initial route and runway
on the navigation map display, but I got distracted by ATC. After we
were airborne, the senior cabin attendant came to the flight deck to tell
us the cabin monitor (which shows the route on a screen to
passengers) showed us in the Canaries instead of the Western
Mediterranean! We continued the flight on raw data only to find out that
the Heading was wrong by about 30-40 degrees. With a ceiling of
1,000 ft at our destination I could not wait to be on 'terra firma'. Now I
always check the Latitude/Longitude three times on initialization!”
EXAMPLE REPORT – PHARMACY
Date of report: March 6th                               Reporter:      Betty
Jones
Date and time of incident: March 6th, 4.30pm
Description of incident: Warning message ignored by doctor. A PEP
(Post-exposure prophylaxis) medication kit was ordered by a doctor in the
emergency department. Standard PEPs contain lopinavir, ritonavir,
zidovudine and lamivudine. The patient was already using several
medications including venlafaxine, amitriptyline, bupropion, and fentanyl.
If this standard PEP had been administered to the patient there may have
been a harmful interaction between the ritonavir and the fentanyl.
When the doctor ordered the PEP, the IT system flagged up a warning
message saying there was a potential drug interaction problem between
ritonavir and fentanyl. This warning was ignored by the doctor, who later
explained to me that she didn‟t read it because she was in a rush.
This interaction is potentially fatal, and I rejected the prescription when I
saw it. An alternative PEP kit was dispensed.
INCIDENT REPORTING
SCHEMES
Reporting incidents, not just accidents, enables organisations
to:
1. Identify why errors and failures occurred.
2. Identify why accidents DON‟T occur.
      •   What are the barriers that stop errors or failures escalating to
          accidents?
3. Produce reminders of known hazards and workarounds and
   generally keep people thinking about safety and improvement
4. Share success stories
5. Allow information to be shared between sites, and
   (sometimes) between organisations
6. Produce adequate quantities of data for understanding
   general issues (human factors, regulatory weakness etc) or
   rare issues.
INCIDENT REPORTING
SCHEMES
Lessons can be drawn from incident reports on an individual
and collective basis:
• Individually:
   • Reports are treated as a “war story”. This way the
      individual report is recounted in a meeting and discussed
      or can be posted in a newsletter.
   • Discussion and learning takes place among practitioners
• Collectively:
    • Reports are collected together and can be analysed to
      identify themes and patterns
    • Lessons have to be drawn out from a manager or
      specialist investigator.
REPORTING RATES
There is an inverse relationship between the number of incidents
reported and the number of accidents
The number of incident reports is not a measure of incidents
• If an organisation has no incident reports, this does not mean it
  has had no incidents.
• If an organisation has many incident reports this does not
  mean that it has had many incidents.


Question: Over a twelve month period, organisation A has 0
incident reports; organisation B has 100; organisation C has 1000.
Which is the safest organisation?
REPORTING RATES
Incident reports in                       1997     2000
            Commercial Aviation:          22,908   26,623
            General Aviation:             8,384    8,501

Accident rates per 100,000 flight hours
            Commercial Aviation:          1.6      3.24
            General Aviation:             7.19     6.3
Accidents
            Commercial Aviation:          147 (21) 148 (26)
            General Aviation:             1845 (350) 1837 (344)
FACTORS INFLUENCING
REPORTING RATES
Professionalism:
• Reflection is an essential aspect of professional practice
• Professional bodies encourage the accumulation of
   knowledge and create circumstances in which this can be
   achieved
• In many cases incident reporting schemes arose from
   professional groups rather than within individual
   organisations
FACTORS INFLUENCING
REPORTING RATES
Trust and Blame
• If someone feels they might be blamed for a report they are
  less likely to write one
    • Blame may be from other practitioners, managers, the
       media/public
• It can also be socially problematic to write reports that
  concern actions by other people
• Organisations with a “blame culture” therefore have
  problems in learning from failure
• Enabling anonymous reporting can avoid issues of blame to
  a certain degree, but successful schemes thrive when there
  is a “culture of trust”.
FACTORS INFLUENCING
REPORTING RATES
Design:
• The design of a scheme also influences its success
• How easy is it to report?
    • Incidents are best reported when they are fresh in your
       mind, and reports are more likely to be completed if it is
       relatively quick and easy to do so.
    • Paper vs electronic forms. Complex vs simple forms.
• Feedback loops are also very important. People are more
  likely to report if they see value in writing reports.
FACTORS INFLUENCING
REPORTING RATES
Why do commercial pilots/crew report more?
1. There is a „no blame‟ environment. Although reports are
   screened for serious offences, the orientation is to looking for
   the root causes of error rather than blaming individuals.
2. There is more education about the value of reporting incidents
3. There is a pro-reporting culture, pilots are reprimanded for
   having too few reports
4. Commercial pilots have more to lose if they fail to report an
   incident. They are more likely to report, especially if they think
   someone else may have seen the incident
5. There is a workable separation between accident reporting
   and incident reporting. The media focus more on accident
   reports.
FACTORS INFLUENCING
REPORTING RATES
In the NHS (England) incident reporting in anaesthesiology fell
massively when hospital wide reporting schemes were launched
in mid 2000s to replace departmental schemes
  •   No atmosphere of trust across hospitals
  •   Complex and cumbersome forms, or direct computer entry
  •   No visible feedback loops
  •   Led to parallel reporting schemes (in some cases reporting
      was done in secret)

The situation improved over time
ANONYMITY AND
REPORTING
The Paradox of anonymity: People often happier to report
anonymously but the reports are of less value to an investigation
There are different ways to handle anonymity in incident reporting
• Open Schemes: Full disclosure of identity of reporter and those
  involved
• Confidential: Disclosure of identities to trusted third parties
• Anonymous: No disclosure of identity
Designing an anonymous system is very difficult. Anonymity is
not a good substitute for trust
• Even if it is not clear who reported, it may be obvious who
  featured in the events described
• People might also be seen reporting, even if what they report
  is not clear.
GENERIC REPORTING
SEQUENCE
           Submit Report



           Assess Report



         Corrective Action



         Publish Report and
          Corrective Action
SIMPLE, SMALL
SCALE SCHEME
    A report is submitted to report coordinator as
           soon as possible after an error


    Report coordinator asks secretary to type up
                       report


    Reports are collated and sent to practitioners
                       monthly


    Reports are discussed in monthly meeting and
              corrective actions decided
LARGE SCALE
 SCHEME
                   Contributor submits report


  Specialists
(human factors,    Third party validates and
 systems, etc)       supplements report.
  contacted if    Submits to management and
   necessary               regulator
                                                   Bank of previous
 Regional and                                            reports
                  Management and regulator           examined for
    national      decide on corrective actions
 investigators                                     similar incidents
  contacted if                                       if necessary
   necessary
                     Incident summary and
                  corrective action published in
                             bulletin
SMALL SCALE SCHEMES

Many incident reporting schemes begin as local, small scale
schemes. For example a scheme might be initiated in one
department in an organisation, or among a local professional group.
  •   Often higher levels of trust
  •   The analysis can more readily draw from contextual knowledge
  •   Focus on quick fixes (“make do and mend” culture)
  •   Can be quick to react
LARGE SCALE
SCHEMES

Large, Organisation-Wide and National Schemes
  • More reports and greater coverage, but with inconsistencies
    between reports
  • More opportunities to look for root causes
  • Greater overheads in analysing reports because of lack of
    contextual knowledge
  • Trust much harder to maintain


International Schemes
  • Some attempts at this, particularly within European Union. Tend
    to focus on bulletins and announcements
OPERATION ORCADIAN
Around ten years ago a boy died during an operation. His
anaesthetic breathing circuit was blocked by a small plastic object.
•   An initial assumption of the police was that this was a deliberate
    act of sabotage
Incident data was drawn together from across the NHS and a
number of incidents were found where small plastic objects were
blocking the breathing circuit
An investigation discovered the likely cause was that plastic caps
from medications were sometimes finding their way into breathing
tubes during storage
Changes were made to the ways in which breathing equipment is
stored
Training was updated
And guidance was issued on how to spot when the breathing circuit
is obstructed
MULTIPLE REPORTING
SCHEMES
A problem other than a lack of reporting, is that some industries have
multiple reporting schemes
  •   Different purposes and audiences
  •   Different jurisdictions and authorities
  •   Different geographic areas
  •   Different approaches to confidentiality
MULTIPLE REPORTING
SCHEMES
UK Nuclear Power Industry
• NUPER (Nuclear Plant Event Reporting): Internal, private
  database of incidents in UK power industry
• UK HSE (Health and Safety Executive): Publishes full incident
  reports, and summary versions
• MHIDAS (Major hazards incidents database service): A
  bibliographic resource, maintained by Safety and Reliability
  Directorate
• INIS (International Nuclear Information System): Coordinated by
  international atomic agency in Austria
• PDR (Public Document Room): USA based resource, links to
  some incident reports and bulletins
MULTIPLE REPORTING
SCHEMES
Aviation - Three schemes is the UK
   • CAA Mandatory Reporting System, and Voluntary Reporting
     System
   • CHIRPS (Confidential Human Factors Incident Reporting
     Programme Scheme)
   • AAIB Air Accident Investigations Board (UK) produces
     monthly bulletins
International Schemes: Civil Aviation Organisation operate the
ADREP Accident/Incident Reporting System.
Europe: European Commission is trying to overcome report
scheme compatibility issues with ECC-AIRS The European Co-
ordination centre for Aircraft Accident Reporting
KEY POINTS
Incident reporting schemes are important to safety. Reports can
focus on errors and near misses as well as failures
Trust is important for a successful schemes, people should not be
blamed for reporting an incident
Reporting schemes need to be well designed if they are to be
effective
Reporting rates do not correlate with incident rates. No reports
does not mean there were no incidents.
Small scale schemes often focus on quick fixes rather than root
causes. Large scale schemes are slower and more bureaucratic
but can be more thorough.
FURTHER READING
C.W. Johnson, Failure in Safety-Critical Systems: A Handbook of Accident
and Incident Reporting, University of Glasgow Press, Glasgow, Scotland,
October 2003.
Full text online: http://www.dcs.gla.ac.uk/~johnson/book/
EXERCISE
1. What is the value of the following reports?
2. Should the people involved be blamed for these incidents?
3. Can you categorise events in these incidents using the GEMS
   slips-lapse-mistake model?
4. What lessons are drawn from these incidents?
5. Do the lessons learned from these incidents address the root
   causes of the problems? If not, why?
A



On pre-flight check I loaded the Flight Management Computer (FMC),
with longitude WEST instead of EAST. Somehow the FMC accepted it
(it should have refused it three times). During taxi I noticed that
something was wrong, as I could not see the initial route and runway
on the navigation map display, but I got distracted by ATC. After we
were airborne, the senior cabin attendant came to the flight deck to tell
us the cabin monitor (which shows the route on a screen to
passengers) showed us in the Canaries instead of the Western
Mediterranean! We continued the flight on raw data only to find out that
the Heading was wrong by about 30-40 degrees. With a ceiling of
1,000 ft at our destination I could not wait to be on 'terra firma'. Now I
always check the Latitude/Longitude three times on initialization!”
B

Date of report: March 6th                               Reporter:      Betty
Jones
Date and time of incident: March 6th, 4.30pm
Description of incident: Warning message ignored by doctor. A PEP
(Post-exposure prophylaxis) medication kit was ordered by a doctor in the
emergency department to reduce the risk of HIV infection to a patient who
had been assaulted.        Standard PEPs contain lopinavir, ritonavir,
zidovudine and lamivudine. The patient was already using several
medications including venlafaxine, amitriptyline, bupropion, and fentanyl.
If this standard PEP had been administered to the patient there may have
been a harmful interaction between the ritonavir and the fentanyl.
When the doctor ordered the PEP, the IT system flagged up a warning
message saying there was a potential drug interaction problem between
ritonavir and fentanyl. This warning was ignored by the doctor, who later
explained to me that she didn‟t read it because she was in a rush.
This interaction is potentially fatal, and I rejected the prescription when I
saw it. An alternative PEP kit was dispensed.
B




Outcome: The pharmacists agree they must be vigilant when drug
interactions have been overridden by doctors. The pharmacists
recognise that doctors in the emergency department are very busy
and that the system does not always meaningfully describe the
seriousness of particular drug interactions.
Reporter: Anon        Patient Sex: Male                                      C
ASA: 2: Relevant systemic disease
Urgency: 1: Routine; on distributed list
Factors: anaesthetist, organisational
The incident caused: 3: Transient abnormality with full recovery
How preventable do you think the incident would be by further
resource? 1: Probably within current resource
What happened? The patient was for direct pharyngoscopy, a short but
stimulating procedure so the plan was to use boluses of alfentanil and
mivacurium. Both these drugs were in correctly labelled 10 ml syringes.
Inadvertently I gave the mivavurium prior to induction instead of
alfentanil. I did not realise my error for a few minutes. The patient initially
appeared drowsy but agitated, breathing became shallow and saturation
dropped to 85%. He developed multple VEs. On realising my error some
propofol was given, the trachea intubated and over a short period of time
his saturation and ECG returned to normal. We continued with the
procedure. On recovery he had recall of what had happened and was
quite distressed by it.
C

Lessons learned:
1. Correctly labelling syringes isn‟t enough, especially when the colour of
the labels is very similar. In this case both the labels that come with the
drug are white. We use other visual aids first, syringe size probably being
the most important.
2. Avoid drawing up muscle relaxants and induction agents in similar size
syringes at the same time as other drugs, ie sux and fentanyl,
thiopentone and augmentin.
3. In this case the part the cause for the error was that I was using a
number of drugs that I dont usually use - thats when you should be extra
vigilant.
Reporter: Anon        Patient Sex:                                            D
ASA: 1: Fit
Urgency: 1: Routine; on distributed list
Factors: Equipment
The incident caused: 2: Transient abnormality unnoticed by patient
How preventable do you think the incident would be by further
resource? 5: Not obviously by any change of practice
What happened? Patient was having a rigid bronchoscopy followed by
submandibular gland excision. The patient was ventilated using a Sanders
injector for the bronchoscopy, connected to the high pressure oxygen outlet
on the anaesthetic machine (Blease Frontoline). Following the
bronchoscopy, the patient was reintubated and conventionally for the next
procedure. However, when the Sanders injector was disconnected from the
oxygen outlet, the outlet valve jammed open, causing a massive leak of
oxygen, enough to cause a complete failure of the anaesthetic gas supply to
the patient. Fortunately, my initial response of fiddling with the leaking valve
led to it closing and restoring normal function. If it had not closed, or another
anaesthetist had reacted differently, the patient would have remained
unventilated until an alternative system of ventilation could be obtained.
Cylinder and piped medical air on the machine were of no value as all the
gas supply was leaking out.
D

Lessons Learned: However good and reliable modern anaesthetic
machines are, catastrophic oxygen failure can always occur – even
bypassing the normal backup of cylinder supply, or medical air supply as
in this case. The new Association of Anaesthetists machine checklist
recommends checking that an alternative means of ventilating a patient is
available and checked – this incident is a good reminder of how important
that can be. I intend to use this incident as a teaching scenario from now
on.
EDINBURGH G-JECI INCIDENT

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CS5032 Lecture 9: Learning from failure 1

  • 2. IN THIS LECTURE Today - two lectures looking at how organisations can investigate and learn from failure • Incident reporting • Accident investigations Incident reporting: • It is important to learn from incidents irrespectively of whether they caused harm • Aviation, Healthcare and the Nuclear industry routinely collect incident data, but with varying success • Collecting incident data can be problematic – mainly because people don‟t want to be blamed for highlighting incidents
  • 3. Accidents are the “tip of an iceberg” • Incidents or “adverse events” are far more common, and underlie accidents. Incident reports highlight faults or report errors and near misses where there was potential for an accident. If incidents are not reported, they may never be noticed by anyone other than those involved What constitutes an incident and whether it warrants reporting can be a judgement http://en.wikipedia.org/wiki/File:Iceberg.jpg
  • 4. INCIDENT REPORTING SCHEMES Incident Reporting Schemes are mechanisms for learning from errors and failures Used in many safety critical domains: • Healthcare, Aviation, Marine, Railways, Nuclear Power, Oil and Chemical Production Increasingly used in complex, business critical environments: • For example Data Centres
  • 5. EXAMPLE REPORT - AVIATION On pre-flight check I loaded the Flight Management Computer (FMC), with longitude WEST instead of EAST. Somehow the FMC accepted it (it should have refused it three times). During taxi I noticed that something was wrong, as I could not see the initial route and runway on the navigation map display, but I got distracted by ATC. After we were airborne, the senior cabin attendant came to the flight deck to tell us the cabin monitor (which shows the route on a screen to passengers) showed us in the Canaries instead of the Western Mediterranean! We continued the flight on raw data only to find out that the Heading was wrong by about 30-40 degrees. With a ceiling of 1,000 ft at our destination I could not wait to be on 'terra firma'. Now I always check the Latitude/Longitude three times on initialization!”
  • 6. EXAMPLE REPORT – PHARMACY Date of report: March 6th Reporter: Betty Jones Date and time of incident: March 6th, 4.30pm Description of incident: Warning message ignored by doctor. A PEP (Post-exposure prophylaxis) medication kit was ordered by a doctor in the emergency department. Standard PEPs contain lopinavir, ritonavir, zidovudine and lamivudine. The patient was already using several medications including venlafaxine, amitriptyline, bupropion, and fentanyl. If this standard PEP had been administered to the patient there may have been a harmful interaction between the ritonavir and the fentanyl. When the doctor ordered the PEP, the IT system flagged up a warning message saying there was a potential drug interaction problem between ritonavir and fentanyl. This warning was ignored by the doctor, who later explained to me that she didn‟t read it because she was in a rush. This interaction is potentially fatal, and I rejected the prescription when I saw it. An alternative PEP kit was dispensed.
  • 7. INCIDENT REPORTING SCHEMES Reporting incidents, not just accidents, enables organisations to: 1. Identify why errors and failures occurred. 2. Identify why accidents DON‟T occur. • What are the barriers that stop errors or failures escalating to accidents? 3. Produce reminders of known hazards and workarounds and generally keep people thinking about safety and improvement 4. Share success stories 5. Allow information to be shared between sites, and (sometimes) between organisations 6. Produce adequate quantities of data for understanding general issues (human factors, regulatory weakness etc) or rare issues.
  • 8. INCIDENT REPORTING SCHEMES Lessons can be drawn from incident reports on an individual and collective basis: • Individually: • Reports are treated as a “war story”. This way the individual report is recounted in a meeting and discussed or can be posted in a newsletter. • Discussion and learning takes place among practitioners • Collectively: • Reports are collected together and can be analysed to identify themes and patterns • Lessons have to be drawn out from a manager or specialist investigator.
  • 9. REPORTING RATES There is an inverse relationship between the number of incidents reported and the number of accidents The number of incident reports is not a measure of incidents • If an organisation has no incident reports, this does not mean it has had no incidents. • If an organisation has many incident reports this does not mean that it has had many incidents. Question: Over a twelve month period, organisation A has 0 incident reports; organisation B has 100; organisation C has 1000. Which is the safest organisation?
  • 10. REPORTING RATES Incident reports in 1997 2000 Commercial Aviation: 22,908 26,623 General Aviation: 8,384 8,501 Accident rates per 100,000 flight hours Commercial Aviation: 1.6 3.24 General Aviation: 7.19 6.3 Accidents Commercial Aviation: 147 (21) 148 (26) General Aviation: 1845 (350) 1837 (344)
  • 11. FACTORS INFLUENCING REPORTING RATES Professionalism: • Reflection is an essential aspect of professional practice • Professional bodies encourage the accumulation of knowledge and create circumstances in which this can be achieved • In many cases incident reporting schemes arose from professional groups rather than within individual organisations
  • 12. FACTORS INFLUENCING REPORTING RATES Trust and Blame • If someone feels they might be blamed for a report they are less likely to write one • Blame may be from other practitioners, managers, the media/public • It can also be socially problematic to write reports that concern actions by other people • Organisations with a “blame culture” therefore have problems in learning from failure • Enabling anonymous reporting can avoid issues of blame to a certain degree, but successful schemes thrive when there is a “culture of trust”.
  • 13. FACTORS INFLUENCING REPORTING RATES Design: • The design of a scheme also influences its success • How easy is it to report? • Incidents are best reported when they are fresh in your mind, and reports are more likely to be completed if it is relatively quick and easy to do so. • Paper vs electronic forms. Complex vs simple forms. • Feedback loops are also very important. People are more likely to report if they see value in writing reports.
  • 14. FACTORS INFLUENCING REPORTING RATES Why do commercial pilots/crew report more? 1. There is a „no blame‟ environment. Although reports are screened for serious offences, the orientation is to looking for the root causes of error rather than blaming individuals. 2. There is more education about the value of reporting incidents 3. There is a pro-reporting culture, pilots are reprimanded for having too few reports 4. Commercial pilots have more to lose if they fail to report an incident. They are more likely to report, especially if they think someone else may have seen the incident 5. There is a workable separation between accident reporting and incident reporting. The media focus more on accident reports.
  • 15. FACTORS INFLUENCING REPORTING RATES In the NHS (England) incident reporting in anaesthesiology fell massively when hospital wide reporting schemes were launched in mid 2000s to replace departmental schemes • No atmosphere of trust across hospitals • Complex and cumbersome forms, or direct computer entry • No visible feedback loops • Led to parallel reporting schemes (in some cases reporting was done in secret) The situation improved over time
  • 16. ANONYMITY AND REPORTING The Paradox of anonymity: People often happier to report anonymously but the reports are of less value to an investigation There are different ways to handle anonymity in incident reporting • Open Schemes: Full disclosure of identity of reporter and those involved • Confidential: Disclosure of identities to trusted third parties • Anonymous: No disclosure of identity Designing an anonymous system is very difficult. Anonymity is not a good substitute for trust • Even if it is not clear who reported, it may be obvious who featured in the events described • People might also be seen reporting, even if what they report is not clear.
  • 17. GENERIC REPORTING SEQUENCE Submit Report Assess Report Corrective Action Publish Report and Corrective Action
  • 18. SIMPLE, SMALL SCALE SCHEME A report is submitted to report coordinator as soon as possible after an error Report coordinator asks secretary to type up report Reports are collated and sent to practitioners monthly Reports are discussed in monthly meeting and corrective actions decided
  • 19. LARGE SCALE SCHEME Contributor submits report Specialists (human factors, Third party validates and systems, etc) supplements report. contacted if Submits to management and necessary regulator Bank of previous Regional and reports Management and regulator examined for national decide on corrective actions investigators similar incidents contacted if if necessary necessary Incident summary and corrective action published in bulletin
  • 20. SMALL SCALE SCHEMES Many incident reporting schemes begin as local, small scale schemes. For example a scheme might be initiated in one department in an organisation, or among a local professional group. • Often higher levels of trust • The analysis can more readily draw from contextual knowledge • Focus on quick fixes (“make do and mend” culture) • Can be quick to react
  • 21. LARGE SCALE SCHEMES Large, Organisation-Wide and National Schemes • More reports and greater coverage, but with inconsistencies between reports • More opportunities to look for root causes • Greater overheads in analysing reports because of lack of contextual knowledge • Trust much harder to maintain International Schemes • Some attempts at this, particularly within European Union. Tend to focus on bulletins and announcements
  • 22. OPERATION ORCADIAN Around ten years ago a boy died during an operation. His anaesthetic breathing circuit was blocked by a small plastic object. • An initial assumption of the police was that this was a deliberate act of sabotage Incident data was drawn together from across the NHS and a number of incidents were found where small plastic objects were blocking the breathing circuit An investigation discovered the likely cause was that plastic caps from medications were sometimes finding their way into breathing tubes during storage Changes were made to the ways in which breathing equipment is stored Training was updated And guidance was issued on how to spot when the breathing circuit is obstructed
  • 23. MULTIPLE REPORTING SCHEMES A problem other than a lack of reporting, is that some industries have multiple reporting schemes • Different purposes and audiences • Different jurisdictions and authorities • Different geographic areas • Different approaches to confidentiality
  • 24. MULTIPLE REPORTING SCHEMES UK Nuclear Power Industry • NUPER (Nuclear Plant Event Reporting): Internal, private database of incidents in UK power industry • UK HSE (Health and Safety Executive): Publishes full incident reports, and summary versions • MHIDAS (Major hazards incidents database service): A bibliographic resource, maintained by Safety and Reliability Directorate • INIS (International Nuclear Information System): Coordinated by international atomic agency in Austria • PDR (Public Document Room): USA based resource, links to some incident reports and bulletins
  • 25. MULTIPLE REPORTING SCHEMES Aviation - Three schemes is the UK • CAA Mandatory Reporting System, and Voluntary Reporting System • CHIRPS (Confidential Human Factors Incident Reporting Programme Scheme) • AAIB Air Accident Investigations Board (UK) produces monthly bulletins International Schemes: Civil Aviation Organisation operate the ADREP Accident/Incident Reporting System. Europe: European Commission is trying to overcome report scheme compatibility issues with ECC-AIRS The European Co- ordination centre for Aircraft Accident Reporting
  • 26. KEY POINTS Incident reporting schemes are important to safety. Reports can focus on errors and near misses as well as failures Trust is important for a successful schemes, people should not be blamed for reporting an incident Reporting schemes need to be well designed if they are to be effective Reporting rates do not correlate with incident rates. No reports does not mean there were no incidents. Small scale schemes often focus on quick fixes rather than root causes. Large scale schemes are slower and more bureaucratic but can be more thorough.
  • 27. FURTHER READING C.W. Johnson, Failure in Safety-Critical Systems: A Handbook of Accident and Incident Reporting, University of Glasgow Press, Glasgow, Scotland, October 2003. Full text online: http://www.dcs.gla.ac.uk/~johnson/book/
  • 28. EXERCISE 1. What is the value of the following reports? 2. Should the people involved be blamed for these incidents? 3. Can you categorise events in these incidents using the GEMS slips-lapse-mistake model? 4. What lessons are drawn from these incidents? 5. Do the lessons learned from these incidents address the root causes of the problems? If not, why?
  • 29. A On pre-flight check I loaded the Flight Management Computer (FMC), with longitude WEST instead of EAST. Somehow the FMC accepted it (it should have refused it three times). During taxi I noticed that something was wrong, as I could not see the initial route and runway on the navigation map display, but I got distracted by ATC. After we were airborne, the senior cabin attendant came to the flight deck to tell us the cabin monitor (which shows the route on a screen to passengers) showed us in the Canaries instead of the Western Mediterranean! We continued the flight on raw data only to find out that the Heading was wrong by about 30-40 degrees. With a ceiling of 1,000 ft at our destination I could not wait to be on 'terra firma'. Now I always check the Latitude/Longitude three times on initialization!”
  • 30. B Date of report: March 6th Reporter: Betty Jones Date and time of incident: March 6th, 4.30pm Description of incident: Warning message ignored by doctor. A PEP (Post-exposure prophylaxis) medication kit was ordered by a doctor in the emergency department to reduce the risk of HIV infection to a patient who had been assaulted. Standard PEPs contain lopinavir, ritonavir, zidovudine and lamivudine. The patient was already using several medications including venlafaxine, amitriptyline, bupropion, and fentanyl. If this standard PEP had been administered to the patient there may have been a harmful interaction between the ritonavir and the fentanyl. When the doctor ordered the PEP, the IT system flagged up a warning message saying there was a potential drug interaction problem between ritonavir and fentanyl. This warning was ignored by the doctor, who later explained to me that she didn‟t read it because she was in a rush. This interaction is potentially fatal, and I rejected the prescription when I saw it. An alternative PEP kit was dispensed.
  • 31. B Outcome: The pharmacists agree they must be vigilant when drug interactions have been overridden by doctors. The pharmacists recognise that doctors in the emergency department are very busy and that the system does not always meaningfully describe the seriousness of particular drug interactions.
  • 32. Reporter: Anon Patient Sex: Male C ASA: 2: Relevant systemic disease Urgency: 1: Routine; on distributed list Factors: anaesthetist, organisational The incident caused: 3: Transient abnormality with full recovery How preventable do you think the incident would be by further resource? 1: Probably within current resource What happened? The patient was for direct pharyngoscopy, a short but stimulating procedure so the plan was to use boluses of alfentanil and mivacurium. Both these drugs were in correctly labelled 10 ml syringes. Inadvertently I gave the mivavurium prior to induction instead of alfentanil. I did not realise my error for a few minutes. The patient initially appeared drowsy but agitated, breathing became shallow and saturation dropped to 85%. He developed multple VEs. On realising my error some propofol was given, the trachea intubated and over a short period of time his saturation and ECG returned to normal. We continued with the procedure. On recovery he had recall of what had happened and was quite distressed by it.
  • 33. C Lessons learned: 1. Correctly labelling syringes isn‟t enough, especially when the colour of the labels is very similar. In this case both the labels that come with the drug are white. We use other visual aids first, syringe size probably being the most important. 2. Avoid drawing up muscle relaxants and induction agents in similar size syringes at the same time as other drugs, ie sux and fentanyl, thiopentone and augmentin. 3. In this case the part the cause for the error was that I was using a number of drugs that I dont usually use - thats when you should be extra vigilant.
  • 34. Reporter: Anon Patient Sex: D ASA: 1: Fit Urgency: 1: Routine; on distributed list Factors: Equipment The incident caused: 2: Transient abnormality unnoticed by patient How preventable do you think the incident would be by further resource? 5: Not obviously by any change of practice What happened? Patient was having a rigid bronchoscopy followed by submandibular gland excision. The patient was ventilated using a Sanders injector for the bronchoscopy, connected to the high pressure oxygen outlet on the anaesthetic machine (Blease Frontoline). Following the bronchoscopy, the patient was reintubated and conventionally for the next procedure. However, when the Sanders injector was disconnected from the oxygen outlet, the outlet valve jammed open, causing a massive leak of oxygen, enough to cause a complete failure of the anaesthetic gas supply to the patient. Fortunately, my initial response of fiddling with the leaking valve led to it closing and restoring normal function. If it had not closed, or another anaesthetist had reacted differently, the patient would have remained unventilated until an alternative system of ventilation could be obtained. Cylinder and piped medical air on the machine were of no value as all the gas supply was leaking out.
  • 35. D Lessons Learned: However good and reliable modern anaesthetic machines are, catastrophic oxygen failure can always occur – even bypassing the normal backup of cylinder supply, or medical air supply as in this case. The new Association of Anaesthetists machine checklist recommends checking that an alternative means of ventilating a patient is available and checked – this incident is a good reminder of how important that can be. I intend to use this incident as a teaching scenario from now on.

Editor's Notes

  1. to reduce the risk of HIV infection to a patient who had been assaulted
  2. Which is safer, Commercial or General Aviation?