James Reason Professor Emeritus University of Manchester

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1 James Reason Professor Emeritus University of Manchester
Säker primärvård Modul 1 Patientsäkerheten måste bli bättre - i primärvården också! James Reason Professor Emeritus University of Manchester The term ‘patient safety’ relates to the unwitting and unintended harm done to patients by healthcare (HC) professionals working within primary care (PC). We have no exact figures relating to the incidence of adverse events, but we know that the problem is huge and it exists everywhere—even in the best-resourced countries of the world. PC professionals are very diverse and widely distributed throughout the community. The problem grows as more and more patients are treated in the primary sector or at home. At first sight, the idea of a patient safety problem is hard to believe. The terms ‘health’ and ‘safety’ go hand in hand; they are almost synonymous. It seems paradoxical, therefore, that HC professionals could be unsafe. It’s also difficult for the professionals to comprehend as well. If your business is to reduce the harm done by disease and injury, it is natural to think of patient safety as something that emerges naturally from the processes of health care. But it isn’t. Safety is never a given. It is something that has to be planned, managed and trained for just like any other HC activity. The main purpose of this module is persuade PC professionals to engage fully in the business of combating adverse patient events. To achieve this, it is necessary to bring about a radical change in culture. This theme runs throughout the entire series of support modules. The modules seek to communicate the overarching principles of error and safety management. They do not link directly to the DVDs. Their purpose is to increase your understanding of the entire series, both DVDs and back up material

2 Primärvård - en mångfacetterad verksamhet.
Primärvård omfattar en mängd olika yrkesgrupper och verksamheter bl.a. Specialister i allmänmedicin Distriktssköterskor Barnmorskor Sjukgymnaster Arbetsterapeuter Psykologer Biomedicinska analytiker Mödrahälsovård, barnhälsovård, hemsjukvård Unlike the secondary sector, the work of primary carers is not conveniently packaged within the neat departments of a large acute care hospital. Rather they are very widely distributed throughout the community, something that makes the issue of culture and patient safety numbers hard to deal with,

3 Att förstå riskerna Primärvården brukar kallas vårdens frontlinje.
Patienter med ett brett spektrum av tillstånd, symtom och sjukdomar ska tas om hand. Att inse när patienten måste remitteras vidare samtidigt som inte remittera allt “för säkerhets skull” är en daglig balansgång, som ställer stora krav på kunskap och erfarenhet hos dem som arbetar i primärvården GPs, in particular, are expected to have a complete knowledge of medicine—an impossible task given the greatly increased complexity of the field. Too much nervousness and caution and there is over-referral; too little attention, experience, and knowledge and dangerous conditions are missed, disguised as they often are by epidemics, or the huge pressure on the practitioner’s time.

4 Patientsäkerhet i siffror
Vi har en hyfsad uppfattning om hur säkerheten är inom sjukhusvården (ca 1 av 10 patienter drabbas eller t.o.m. dör pga. vårdskador). Siffror för primärvården saknas. En sak är emellertid säker: risken för att patienterna ska drabbas av en vårdskada även i primärvården är stor - och den ökar. In obtaining these and other figures quoted here, we have leaned very heavily on the excellent publication ‘Seven Steps to Patient Safety for Primary Care’, written largely by Dr Suzette Woodward and published by the National Patient Safety Agency in 2006 (latest version). In full, it runs to over a 160 pages, but each section can be down loaded separately. We strongly urge that you consult this document extensively. It provides an ideal supplement to this entire package.

5 Fler siffror 2009 gjordes 1,48 besök hos läkare per invånare och 2,37 besök hos andra personalkategorier inom primärvården. 80 % av patienter med diabetes behandlas i primärvården. Årligen görs >2 miljoner läkemedelsförskrivningar av distriksläkare och distriktsköterskor There is a basic rule in error management. The more you do, and the more frequently you do it, the greater is the opportunity for error. This has nothing to do with skills or competence: it is simply a bleak arithmetical fact, and it applies in all areas of hazardous work. With a million PC consultations a day, it only takes a very few of them to go wrong to produce a very large number of adverse events.

6 Primärvården förändras
Många små enheter och många olika vårdproducenter. Kortare vårdtider på sjukhus. Svårt sjuka patienter, som tidigare vårdades på sjukhus, behandlas numera i primärvården. Kommunernas större ansvar för hemsjukvård, innebär större behov av t.ex. läkarinsatser i denna vårdform. There have been tremendous changes in the way health care is delivered in the UK. The net result has been to bring more and more patients into prolonged contact with primary carers. While this may greatly improve patient comfort, convenience and well-being, it also brings with it a very large increase in the opportunity for adverse events in the primary sector.

7 Patientsäkerhetsdata från allmänpraktiker i Manchester
I mellan gånger per besök sker ett misstag. Vanliga misstag är felaktiga eller missade diagnoser. Andra vanliga misstag rör läkemedel inklusive missade biverkningar samt hela remisshanteringen. I 21 % av de rapporterade fallen, har patienten avlidit till följd av sin vårdskada.

8 Fler siffror Vid en engelsk studie 2003 av tio allmän-läkarmottagningar upptäcktes 940 avvikelser under en två-veckorsperiod i 7,5 % av besöken skedde avvikelse. 42 % av avvikelserna skedde vid läkemedels-förskrivningar. 30 % var kommunikationsrelaterade (vanligast var att journalanteckningar saknades) 3 % bestod av felaktiga journalanteckningar.

9 Fakta från USA De flesta misstagen inom primärvårds-liknande verksamhet faller inom två kategorier: Brister i kommunikationen Brist på klinisk färdighet och/eller kunskap. De viktigaste områdena att förbättra är därför diagnosticering, läkemedelsförskrivning och all sorts kommunikation mellan olika vårdgivare.

10 Den mänskliga faktorn (som andel av alla misstag)
Flygtransporter % Flygledning % Fartyg % Kemisk industri % Kärnkraftverk (USA) % Vägtransporter % These numbers give you a clear idea of the very large extent to which human errors are implicated in adverse events in a wide range of industries. Thirty years ago, the percentages would have been much smaller—not because people have become more fallible, but because there have been enormous technical improvements in the reliability of equipment. Human error now represents the main residual category of system failure. Again, this is due to technological changes such as centralisation and automation. Fewer people control more complex systems. Not only that, they also design, build, maintain and manage them. It is thus inevitable that people and organisations should now feature so largely in tables like the one above. As elsewhere, human performance problems pose the largest single risk to patient safety. They are often referred to as ‘medical errors’, but the only thing specifically medical about them is the HC context in which they occur. In all other respects, errors take the same basic forms in all fields of human activity. This is important to appreciate, since we can learn a great deal about how to manage error from these other domains. Att en människa gör fel, är den största risken i all farlig verksamhet.

11 Misstag och sjukvård I vården har man relativt sent förstått att mänskliga misstag utgör de största hoten mot patientsäkerheten. Misstag inom andra områden (t.ex. flyget) kan orsaka mycket uppenbara katastrofer. Inom sjukvården däremot är det alltid enstaka individer på många olika ställen som drabbas av skador. Human nature being what it is, widespread worries about safety are usually sparked off by some horrendous and well-publicised disaster. But there has been no such dramatic wakeup call for patient safety. There has been no public or media outcry of the kind that follows a major rail or aircraft crash. Although the victims of medical injury are frighteningly numerous, they tend to be buried quietly, one by one, in many different places.

12 Cirka en av tio patienter är i riskzonen
Olika studier av patientsäkerheten i sjukhusvård ger likartade resultat Storbritannien: 11 % Nya Zeeland: 10 % Danmark: 9 % Australien:11% Kanada: 8 % generellt, 11 % vid universitetssjukhus Sverige: 8,6 % This slide shows that around one in ten of those admitted to an acute care hospital suffer an adverse event. These AEs vary in severity from minor injury to death. In the most recent (Canadian) study, for example, found that 64.4% of the AEs resulted in no physical impairment or disability, or in minimal to moderate impairment with recovery in 6 months. However, 5.2% of the AEs resulted in permanent disability and 15.9% of AEs resulted in death. It was estimated that death would be associated with an AE in roughly 2% of patients with similar hospitalizations in Canada. Just think for a moment what these numbers mean. One in ten people receiving treatment in acute care hospitals is harmed; two in a hundred are killed by medical error. These are staggering proportions. Cirka en av tio patienter är i riskzonen

13 Hur farlig är sjukvården?
This slide compares HC with other potentially hazardous activities and industries. It is exceedingly dangerous: comparable to mountain climbing in the risk of a fatality, and exceeding road traffic accidents in the number of people killed each year.

14 Problemet är stort oavsett alla siffor - och det existerar överallt.
Vi måste samla in, analysera och sprida information om brister i patientsäkerheten (så att vi kan lära oss av varandras misstag.) finasiera forskning om patientsäkerhet. åtgärda brister i systemen – inte fokusera på enskilda individer. erkänna betydelsen av en god säkerhetskultur. identifiera ständigt återkommande risker i det kliniska arbetet. This slide summarises the areas of agreement between these various high-level reports. A major emphasis was upon establishing agencies to collect, analyse and disseminate information about adverse events. It was also agreed that the primary focus should be upon improving the various systems of health care rather than upon the fallible individuals. This approach is discussed at length in subsequent modules.

15 Kom ihåg Uttrycket "medicinskt fel" skulle kunna uppfattas som fel som är unika för sjukvård. Så är dock inte fallet. De skiljer sig inte från misstag som människor gör i all verksamhet. Det är sammanhanget som är unikt för sjukvården – inte misstagen i sig. Regler för riskhantering är generella för all verksamhet. We have made the point about the non-uniqueness of ‘medical error’, but it bears repeating because it allows us to draw upon the large literature relating to human error and its management in other hazardous domains.

16 Riskhantering har tre delar
Reducera antalet avvikelser Begränsa konsekvenserna av avvikelser Få riskhanteringen att fungera Det svåraste är att få alla delar att fungera. Metoder och hjälpmedel kan bara ge bestående förbättringar om de stöds av en god säkerhetskultur. Human being are fallible. We can’t change the human condition, but we can change the conditions under which humans work. This process is called error management, and will be discussed in Modules 3 and 4.

17 Lär av andra områden - men kom ihåg att sjukvård är sjukvård
Det är naturligt och viktigt att studera säkerhetskultur och modeller för riskhantering i andra komplexa högrisk-verksamheter t.ex. flyg och kärnkraftsverk. Men kom ihåg att sjukvårdsverksamhet är annorlunda på flera avgörande sätt. Anaesthetists, pioneers in patient safety, have long looked to domains like aviation, nuclear power and chemical process plants. Like pilots and control room operators they are the supervisory controllers of complex processes that can only be sensed remotely—a development that depends largely upon sophisticated computer technology. As indicated in the previous slide, there are excellent reasons for seeking to learn from these other domains. However, while there are similarities, as between anaesthetists and pilots, and while HC institutions like commercial aircraft and nuclear power plants are complex well-defended systems, there are also many important differences.

18 Även om Även om alla visste allt som är värt att veta inom sjukvården, skulle misstag ske. De är - liksom resten av mänskligheten - inte ofelbara. Men det faktum att de inte utbildas för att förstå, förvänta, upptäcka eller hantera sina egna misstag är kärnan i patientsäkerhetsproblematiken. But even if HC professionals were omniscient and knew everything about all conditions, they would still make errors. Why? Quite simply because they are human and fallibility is the downside of having a brain. However, HC professionals are trained in an environment in which fallibility is not readily acknowledged. This is in sharp contrast to aviation as the next slide explains.

19 En enorm kulturskillnad
Sjukvårdsutbildningar är långa, mödosamma och dyra och har en begriplig förväntan att alla ska göra rätt. Kulturen i vården uppmuntrar inte till diskussion och lärande av egna eller andras misstag. Flygbranschen däremot utgick redan från början från att människor kan förväntas begå misstag. Vem hittade på den första checklistan - Wilbur eller Orville? Aviation (now in its hundredth year) was always predicated upon the assumption that people will always make errors. Right from the beginning, they developed error management tools—like checklists—to reduce the likelihood of error and to increase the detection and correction errors made previously. It is crucial that HC professionals break free of the myth of medical infallibility. Errors happen in all fields of human activity. The trick is to recognise their inevitability. This means understanding the nature of error and the psychological and situational factors that provoke it. Errors are not random events. They take very predictable forms—and the same situations keep on producing the same kinds of error in a wide variety of different people. The existence of these ‘error traps’ shows that the major challenge is to identify and eliminate these error-prone situations. We must also stop treating errors as a moral issue. Fallibility is the norm, not the exception. There are many pressures upon HC professionals to bury their mistakes. This creates the impression that only bad doctors make bad errors. But one of the basic rules of human error is that the best people can sometimes make the worst mistakes.

20 Antal händelser över tid – ett vanligt mönster.
En god nyhet. Det är lättare att åstadkomma förbättring i kurvans början Antal händelser Sjukvård Flygbranschen One common feature of safety management in any hazardous domain is that the number of adverse events declines exponentially over time—rapidly at first and then levelling out into a slowly declining plateau. Commercial aviation has now reached the point where there is little year on year reduction in serious accidents. The number of fatal aircraft accidents is very small indeed, the risks being less than one in a million. But HC is still high up the curve where remedial actions have a dramatic impact on reducing adverse events. Visible improvements are powerful motivators for further efforts to enhance patient safety. Tid

21 DÅLIGA NYHETER - säkerhetsarbetet måste pågå jämt.
I flertalet riskfyllda branscher får säkerheten hög prioritet först när något allvarligt har inträffat. Och risken är stor att prioriteringen sjunker efter tag. Vården har inte haft någon “big bang”, som skakat om hela branschen. Det kommer bara rapporter om enstaka händelser, som inte kan förväntas få någon kvarstående betydelse. Sjukvården måste använda alla enstaka händelser, som underlag i sitt patientsäkerhetsarbete. The bad news, however, is that safety rarely stays at the top of the priority list. Production pressures reassert themselves quite rapidly, and it is production that pays for safety, rather than the other way around. HC is unusual in not having had a ‘big bang’. Current initiatives have been driven by influential figures at the top of HC hierarchies and by a growing awareness of the extent of the patient safety problem. But how long will these drivers last? A recent editorial in the New England Journal of Medicine (D. Berwick, June 19, 2003) identifies four reasons why progress in patient safety has been so slow in the United States The studies cited earlier do not necessarily conform to the personal experiences of individual HC professionals. If 100 patients die from iatrogenic injuries each day in US hospitals, and there are 5000 hospitals, that works out at 1 patient per hospital every 2 months—a virtually non-observable statistic. Health carers still cling to primitive moralistic views about error. Bad errors can only be caused by bad people, and so on (see Module 3). Improving safety costs money and resources in the short term. This is not attractive to hard-pressed hospital managers faced with a long list of productive demands. Improving safety is not an easy business. We can never anticipate all the various ways in which harm can come to patients. Effective error management requires abandoning long-standing and well-ingrained habits of practice.

22 En radikal förändring av säkerhetskulturen behövs.
Nästan all personal som varit inblandad när en patient har skadats bär på skuldkänslor. Sjukvården har en kultur som alltför ofta tolererar och accepterar att patienter drabbas av undvikbara vårdskador, dåliga arbetsförhållanden "genvägar“ för att klara jobbet en informell tystnadskod om vårdskador Almost every HC professional carries a burden of guilt, sometimes a very painful one. At one time or another, nearly all of them have caused unwitting and unintended harm to patients. And if they haven’t, then they most likely will in the future. The burden is made particularly onerous not only because causing harm to a patient was the very last thing they wanted to do, but because the whole ethos of medical training leads HC professionals to believe that such lengthily and expensively acquired expertise will ensure that they will get things right. But the numbers tell a different story. HC professionals are just like the rest of us. They are human and make mistakes—and will continue to do so. But medical errors do not inevitably lead to adverse events. Good HC professionals acquire the ability to detect and recover their errors before they do harm. This is a skill and it needs to be taught and practised during HC training just like any other skill. But this won’t happen until there is a radical cultural change that acknowledges that HC activities, by their very nature, are highly error-provocative. We must recognise that errors are consequences as well as causes. They are not simply the product of incompetence or perversity. The psychological antecedents of error—inattention, preoccupation, distraction or forgetfulness—are often the last and least manageable part of a story that extends back to working conditions, the system at large and, perhaps most importantly, the organisational and professional culture.

23 Kom ihåg Radikala förbättringar kräver att man måste pröva sig fram (trial-and-error). Fel och misstag är ofrånkomliga – men visar också var förbättringsbehoven finns. Förmågan att upptäcka och åtgärda risker är avgörande för patientsäkerheten – bli riskmedveten. Lär läxorna globalt i stället för lokalt dvs. inhämta aktuell säkerhetskunskap och lär av andra.