Patient Safety and Nursing
Professionals
Bachchu Kailash Kaini
Clinical Governance Manager, Queen Elizabeth Hospital
Health Care: A Risky Business




―If you fly in a plane you have a 1 in 10 million
chance of being killed ...
If you go into hospital you have a 1 in 300 chance
and not from the illness you went in with‖
Sir Richard Branson, Vice President
of the Patient‘s Association





Number of Healthcare Diagnoses listed? > 68,000
Number of Healthcare Procedures available? > 6,000
Number of Healthcare Medications available? > 4,000
January 2010
Patient Safety






‗reduce the risk of adverse events related to
exposure to medical care across a range of
diagnoses or conditions‘ (Shojania et al, 2001)
An essential part of nursing care (NMC Code,
2008 and RCN Principles of Nursing Practice,
2010)
Everyone‘s business
Reference/Courtesy: Patient Safety and Quality: An Evidence-Based Handbook for Nurses.
Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.
Nurses Responsibility




Nursing care: different aspects of patient care –
e.g. avoiding medication errors and preventing
patient falls
Broader level: ability to coordinate and integrate
the multiple aspects of quality
 Collaboration
 Assessment
 Surveillance
 Monitoring
Evidences




Greater percentage of registered nurses to other
nursing staff is associated with fewer
complications and lower mortality (Tourangeau et
al, 2006).
The lower the proportion of professional nursing
staff employed on a unit, the higher the number
of medication errors and wound infections. The
less experienced the nurse, the higher the
number of wound infections. (McGillis Hall et al,
2004).
Top Three Issues




Pressure ulcers
Slips, trips and falls
Medication errors
Recent Reports

Keogh Report, July 2013

Berwick Report, Apr 2013 Francis Report, Feb 2013
Implications


Mid Stafford Hospital Scandal: 'Nurse count' will
be introduced to improve patient safety










Bosses at each hospital will be forced to make public the number
of nurses working on each ward (Mirror, 19 Nov 2013)

Criminal offence for wilful neglect
Duty of Candour
Attitude test for compassion and caring
Consistent training - common qualification/
assessment across HCPs
Appraisals
Nursing leadership
Traditional Health Care Culture
Mistakes occur because people are:
 Inattentive, lazy, careless, negligent & unreliable
 Those responsible are identified, blamed, retrained and disciplined
 Embarrassment to the organisation is reduced
Consequences of a Person Centred
Approach






Close ranks
Cover up
Admit nothing
Tell no one
Pretend nothing happened
Modern Focus




Organisational structures and systems
influence on the individual leads to
mistakes/unplanned outcomes
The best way to reduce patient safety
incidents is to target the underlying systems
failures, rather than take action against
individual members of staff
Human Error
―We all make errors irrespective of how much
training and experience we possess or how
motivated we are to do it right‖.




(in reducing error and influencing behaviour - HSG48)

Unintended, unavoidable (or voidable) and
unexpected (or expected) incidents
Requirements for Change







An open culture
A just culture
A reporting culture
A learning culture
An informed culture
Learning Lessons


"I have not failed. I've just found 10,000 ways
that won't work.“ —Thomas Edison
Thank You.
For further contact:
bkaini@nhs.net

Patient Safety and Nursing Professional

  • 1.
    Patient Safety andNursing Professionals Bachchu Kailash Kaini Clinical Governance Manager, Queen Elizabeth Hospital
  • 2.
    Health Care: ARisky Business   ―If you fly in a plane you have a 1 in 10 million chance of being killed ... If you go into hospital you have a 1 in 300 chance and not from the illness you went in with‖ Sir Richard Branson, Vice President of the Patient‘s Association    Number of Healthcare Diagnoses listed? > 68,000 Number of Healthcare Procedures available? > 6,000 Number of Healthcare Medications available? > 4,000 January 2010
  • 3.
    Patient Safety    ‗reduce therisk of adverse events related to exposure to medical care across a range of diagnoses or conditions‘ (Shojania et al, 2001) An essential part of nursing care (NMC Code, 2008 and RCN Principles of Nursing Practice, 2010) Everyone‘s business
  • 4.
    Reference/Courtesy: Patient Safetyand Quality: An Evidence-Based Handbook for Nurses. Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.
  • 5.
    Nurses Responsibility   Nursing care:different aspects of patient care – e.g. avoiding medication errors and preventing patient falls Broader level: ability to coordinate and integrate the multiple aspects of quality  Collaboration  Assessment  Surveillance  Monitoring
  • 6.
    Evidences   Greater percentage ofregistered nurses to other nursing staff is associated with fewer complications and lower mortality (Tourangeau et al, 2006). The lower the proportion of professional nursing staff employed on a unit, the higher the number of medication errors and wound infections. The less experienced the nurse, the higher the number of wound infections. (McGillis Hall et al, 2004).
  • 7.
    Top Three Issues    Pressureulcers Slips, trips and falls Medication errors
  • 8.
    Recent Reports Keogh Report,July 2013 Berwick Report, Apr 2013 Francis Report, Feb 2013
  • 9.
    Implications  Mid Stafford HospitalScandal: 'Nurse count' will be introduced to improve patient safety        Bosses at each hospital will be forced to make public the number of nurses working on each ward (Mirror, 19 Nov 2013) Criminal offence for wilful neglect Duty of Candour Attitude test for compassion and caring Consistent training - common qualification/ assessment across HCPs Appraisals Nursing leadership
  • 10.
    Traditional Health CareCulture Mistakes occur because people are:  Inattentive, lazy, careless, negligent & unreliable  Those responsible are identified, blamed, retrained and disciplined  Embarrassment to the organisation is reduced
  • 11.
    Consequences of aPerson Centred Approach      Close ranks Cover up Admit nothing Tell no one Pretend nothing happened
  • 12.
    Modern Focus   Organisational structuresand systems influence on the individual leads to mistakes/unplanned outcomes The best way to reduce patient safety incidents is to target the underlying systems failures, rather than take action against individual members of staff
  • 13.
    Human Error ―We allmake errors irrespective of how much training and experience we possess or how motivated we are to do it right‖.   (in reducing error and influencing behaviour - HSG48) Unintended, unavoidable (or voidable) and unexpected (or expected) incidents
  • 14.
    Requirements for Change      Anopen culture A just culture A reporting culture A learning culture An informed culture
  • 15.
    Learning Lessons  "I havenot failed. I've just found 10,000 ways that won't work.“ —Thomas Edison
  • 16.
    Thank You. For furthercontact: bkaini@nhs.net

Editor's Notes

  • #9 Keogh Reports - inadequate numbers of nursing staff in a number of ward areas, particularly out of hours - at night and at the weekend. Berwick Report – 8 Recommendations and Francis report – Out of 290, they have said they accept 204 in full, 57 in principle and 20 in part.
  • #11 PERSON-CENTRED APPROACH
  • #12 Feelings of GUILT and SHAME
  • #13 OPEN: staff comfortable to discuss patient safety incidents / raise concerns with colleagues / senior managersJUST: staff / patients / carers treated fairly, with empathy/consideration when involved in PSI / raising concerns NOT blamed or punishedREPORTING: staff have confidence in incident reporting system – use to report near miss and actual incidents / receive constructive feedback / easy to reportLEARNING: committed to learn from incidents / communicates lessons / organisational memoryEXEC / SENIOR MANGERS LEAD BY EXAMPLE…..
  • #14 OPEN: staff comfortable to discuss patient safety incidents / raise concerns with colleagues / senior managersJUST: staff / patients / carers treated fairly, with empathy/consideration when involved in PSI / raising concerns NOT blamed or punishedREPORTING: staff have confidence in incident reporting system – use to report near miss and actual incidents / receive constructive feedback / easy to reportLEARNING: committed to learn from incidents / communicates lessons / organisational memoryEXEC / SENIOR MANGERS LEAD BY EXAMPLE…..
  • #15 OPEN: staff comfortable to discuss patient safety incidents / raise concerns with colleagues / senior managersJUST: staff / patients / carers treated fairly, with empathy/consideration when involved in PSI / raising concerns NOT blamed or punishedREPORTING: staff have confidence in incident reporting system – use to report near miss and actual incidents / receive constructive feedback / easy to reportLEARNING: committed to learn from incidents / communicates lessons / organisational memoryEXEC / SENIOR MANGERS LEAD BY EXAMPLE…..