III International Conference
       on Patient Safety
           Madrid
      13th December 2007




    Margaret Murphy
INTRODUCTION
BRIEF
  Personal Experience
  World Alliance Patients for Patient Safety Strategy
  Opportunities for Collabo...
Official Data Item
Kevin The Person
8 Days before   100
admission to
                80
  hospital
                60
                                  East
 ...
The Questions

Simple questions…..

              Why did Kevin die?
              What went wrong?

 - we need to know an...
Every Point
of Contact
Failed Him…
The Unfolding Story
                     1997-1999
Persistent back pain – GP Visits, X-Rays
Orthopaedic Surgeon – Bone Sca...
You ignore at your peril
the concerns of a mother
Peer Review

“The combination of bone pain, renal
failure and hypercalcaemia in a
young patient points either to a
diagnos...
Every Point
of Contact
Failed Him…
The Post-It
Every Point of Contact
Failed Him…
The Shortcomings

•   Inability to recognise seriousness of Kevin’s condition
•   Appropriate interventions not taken
•   ...
Shortcomings Contd…


•   Treatment at Registrar level
•   The team dynamic
•   The impact of a weekend admission
•   Pati...
Responses

•Initially honest & humane
          --------------------
•Defensiveness
•‘Loyalty to colleagues’
•Muddying the...
Legal Route to Finding
             Answers

•   System favours defendants
•   Disempowerment of plaintiff
•   Plaintiff t...
Court Ruling


“It is very clear to me that Kevin

 Murphy should not have died.”

 Judge Roderick Murphy at High Court Ru...
A Wish List : Do it Right!

• Observe existing guidelines, best practice and SOP’s. Be
  prepared to challenge each other ...
A Wish List …..Continued

• Know your personal limitations
• Replicate what is good and be always vigilant for
  opportuni...
4 Most Dangerous Words


       It
    Couldn’t
    Happen
     Here
Barriers to Progress

Inappropriate responses and their role in relation to
fuelling confrontation?
Inaccessibility of par...
A Better Way


       Sir Liam Donaldson
A humane and life-giving encounter
Patients & Families
                     – the Untapped Resource -
                  Why Patients for Patient Safety?

The...
Formational Workshops
Champion Activities

 different aspects of patient safety, speaking at conferences and to
 medical students
 Connecting wi...
Impact on and by Champions

“The Workshop united all efforts
of patients from different
regions of Ukraine. Now I can
see ...
Patient Engagement & Education
A Better Way (2)
        Disclosure, Openness, Transparency


•   Dr Van Pelt & Linda Kenney
•   AMA Code of Ethics
•   Th...
RAPS Code of Ethics

Conducting actions in compliance with the existing
laws and regulations
Being competent
Being committ...
Ensuring that information and communications,
whether oral or written, are accurate and complete.
Being able to withstand ...
W.H.O. / H.I.Q.A. Project

                  DRIVING LEARNING
while supporting patients, families and clinicians
         ...
PARTNERSHIP
     COLLABORATION




      DIALOGUE
          =
POWERFUL CONVERSATION
The London Declaration
                     .... an excerpt

We Patients for Patient Safety will be the voice for all peop...
“To err is human, to cover up is unforgivable
              and to fail to learn is inexcusable.”
               - Sir Lia...
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Patients for patient safety

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Patients for patient safety. Margaret Murphy. III International Conference on Patient Safety: "Patients for Patient Safety" (Madrid, Ministry of Health and Consumer Affairs, 2007)

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Patients for patient safety

  1. 1. III International Conference on Patient Safety Madrid 13th December 2007 Margaret Murphy
  2. 2. INTRODUCTION BRIEF Personal Experience World Alliance Patients for Patient Safety Strategy Opportunities for Collaborative Effort CONSIDERATIONS Adverse events as catalysts for change Patient Experience Perceived as Anecdote vs Evidence Based The challenge of learning from the patient experience – acknowledging the mismatch between the actual and the ideal SIMPLE MEASURES SAVE LIVES!
  3. 3. Official Data Item
  4. 4. Kevin The Person
  5. 5. 8 Days before 100 admission to 80 hospital 60 East 40 West 20 North 0 1st 3rd Qtr Qtr
  6. 6. The Questions Simple questions….. Why did Kevin die? What went wrong? - we need to know and we need to understand -
  7. 7. Every Point of Contact Failed Him…
  8. 8. The Unfolding Story 1997-1999 Persistent back pain – GP Visits, X-Rays Orthopaedic Surgeon – Bone Scan, Blood Tests 1997 1999 •Calcium 3.51 (2.05-2.75) 5.73 (6.1) Described as ‘inconsistent with life’. •Creatinine 141 (60-120) 214 •Urate 551 (120-480) 685 •Bilirubin Direct 9.9 (0-6) •Alk Phosphate 489 (90-300)
  9. 9. You ignore at your peril the concerns of a mother
  10. 10. Peer Review “The combination of bone pain, renal failure and hypercalcaemia in a young patient points either to a diagnosis of primary hyperparathroidism or metastatic malignancy and these ominious results should have been investigated as a matter of urgency”. “All the evidence indicates that the “Kevin would have had surgery to patient was suffering from a solitary remove the over-active parathyroid parathyroid adenoma at the time, gland. He would have been cured removal would have been curative with and would still have been alive a normal life expectancy” today.” Research 96% Success; 1% Complication Rates
  11. 11. Every Point of Contact Failed Him…
  12. 12. The Post-It
  13. 13. Every Point of Contact Failed Him…
  14. 14. The Shortcomings • Inability to recognise seriousness of Kevin’s condition • Appropriate interventions not taken • Selective and incomplete transmission of information. • Non receipting of vital information • Absence of integrated pathways • Link between behaviour and test results not made • Developing neurological problems ignored • No evidence of tracking of his deteriorating condition ABSENCE OF DIRECT COMMUNICATION WITH THE PATIENT
  15. 15. Shortcomings Contd… • Treatment at Registrar level • The team dynamic • The impact of a weekend admission • Patient asked to accommodate system? • Expectations of a Tertiary Training Hospital
  16. 16. Responses •Initially honest & humane -------------------- •Defensiveness •‘Loyalty to colleagues’ •Muddying the waters •Dissembling •Unsustainable excuses --------------------- •Confidence in any hope of ascertaining truth shattered •Expectation of professional and honourable conduct betrayed
  17. 17. Legal Route to Finding Answers • System favours defendants • Disempowerment of plaintiff • Plaintiff takes huge personal risks • “David and Goliath” experience • Wearing-down process • Lack of compassion
  18. 18. Court Ruling “It is very clear to me that Kevin Murphy should not have died.” Judge Roderick Murphy at High Court Ruling Dublin, Ireland, May 2004
  19. 19. A Wish List : Do it Right! • Observe existing guidelines, best practice and SOP’s. Be prepared to challenge each other in that regard • Following adverse outcomes undertake “root cause analysis” quot;system failure analysisquot;/quot;critical incident investigation”. • Communicate effectively within the medical community and with patients • Keep impeccable records • Listen to patients and families • Respect patients and families ACKNOWLEDGE ERROR AND ALLOW LEARNING TO OCCUR
  20. 20. A Wish List …..Continued • Know your personal limitations • Replicate what is good and be always vigilant for opportunities to improve. • Learn and disseminate that learning • Practice dialogue and collaboration – meaningful engagement with patients and families • Create a coalition of healthcare professionals and patients ACKNOWLEDGE ERROR AND ALLOW LEARNING TO OCCUR
  21. 21. 4 Most Dangerous Words It Couldn’t Happen Here
  22. 22. Barriers to Progress Inappropriate responses and their role in relation to fuelling confrontation? Inaccessibility of partnership and collaborative opportunities to ordinary patients and families The culture of medical practice that has isolated physicians and forced them to live out of a perception of infallibility and faultless performance Fears relating to litigation and loss of reputation. Excluding the patient and family from the change process. Neglecting to learn from industry
  23. 23. A Better Way Sir Liam Donaldson A humane and life-giving encounter
  24. 24. Patients & Families – the Untapped Resource - Why Patients for Patient Safety? The perspective and partnership of patients, their families and health consumers all over the world… is central to the patient safety work of WHO is crucial to articulating the reality and identifying the gaps between the possible patient safety improvements and actual improvements as experienced by patients. is necessary to ensure services are driven by patient need and are authentically patient-centred Is a useful validation tool in relation to the implementation of guidelines, processes and protocols. The need for the patient voice in the global arena of healthcare
  25. 25. Formational Workshops
  26. 26. Champion Activities different aspects of patient safety, speaking at conferences and to medical students Connecting with our country offices of WHO Establishing our own patient safety organizations. Writing in local or national publications and journals Networking. Patient safety commissions, task forces, committees addressing Fundraising Dedicated projects In addition to supporting patient champions P4PS is also focusing on: (i) advancing patient involvement/engagement as a patient safety solution (ii) arriving at an understanding of what patients and families want in relation to disclosure and learning from adverse events
  27. 27. Impact on and by Champions “The Workshop united all efforts of patients from different regions of Ukraine. Now I can see that I am not alone in my desire to change the system. I am not alone in my grief also. There are some people that have passion to do something Ukrainian Champions good in this domain. Barbara That Kiev workshop gave me Farlow more strength and more belief that we can do Ed Mendoza something.” - F. Petkanych Canadian Champions
  28. 28. Patient Engagement & Education
  29. 29. A Better Way (2) Disclosure, Openness, Transparency • Dr Van Pelt & Linda Kenney • AMA Code of Ethics • The Sorry Works Coalition • US Mass hospital experience • Canada, Australia and Denmark
  30. 30. RAPS Code of Ethics Conducting actions in compliance with the existing laws and regulations Being competent Being committed to continual learning while being able to acknowledge areas that are outside of your expertise. Not being unduly influenced by competing or conflicting interests. Being principled, consistent and possessing integrity
  31. 31. Ensuring that information and communications, whether oral or written, are accurate and complete. Being able to withstand challenges to our views, while at the same time being accountable for mistakes. Being just in considering the interests of all parties. Being respectful of others – treating all individuals with dignity and courtesy
  32. 32. W.H.O. / H.I.Q.A. Project DRIVING LEARNING while supporting patients, families and clinicians when things go wrong Framework for Reporting and Learning Preserving the relationship of trust Giving meaning to tragedy Acknowledging error and allowing learning to occur Feedback to patients and families
  33. 33. PARTNERSHIP COLLABORATION DIALOGUE = POWERFUL CONVERSATION
  34. 34. The London Declaration .... an excerpt We Patients for Patient Safety will be the voice for all people, but especially those who are now unheard. Together as partners, we will collaborate in: Devising and promoting programmes for patient safety and patient empowerment Developing and driving constructive dialogue with all partners concerned with patient safety Establishing systems for reporting and dealing with medical harm on a worldwide basis Defining best practice in dealing with medical harm of all kinds, and promoting those practices
  35. 35. “To err is human, to cover up is unforgivable and to fail to learn is inexcusable.” - Sir Liam Donaldson, Chair, World Alliance for Patient Safety Thank You December 2007 m33g33t@yahoo.co.uk

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