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Patients for patient safety

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Plan de Calidad para el SNS
Plan de Calidad para el SNS

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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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 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!
Official Data Item
Kevin The Person
8 Days before 100 admission to 80 hospital 60 East 40 West 20 North 0 1st 3rd Qtr Qtr
The Questions Simple questions….. Why did Kevin die? What went wrong? - we need to know and we need to understand -
Every Point of Contact Failed Him…
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)
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 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
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 • 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
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
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
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
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
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
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
4 Most Dangerous Words It Couldn’t Happen Here
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
A Better Way Sir Liam Donaldson A humane and life-giving encounter
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
Formational Workshops
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
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
Patient Engagement & Education
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
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
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
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
PARTNERSHIP COLLABORATION DIALOGUE = POWERFUL CONVERSATION
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
“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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Patients for patient safety

  • 1. III International Conference on Patient Safety Madrid 13th December 2007 Margaret Murphy
  • 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!
  • 5. 8 Days before 100 admission to 80 hospital 60 East 40 West 20 North 0 1st 3rd Qtr Qtr
  • 6. The Questions Simple questions….. Why did Kevin die? What went wrong? - we need to know and we need to understand -
  • 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. You ignore at your peril the concerns of a mother
  • 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
  • 13. Every Point of Contact Failed Him…
  • 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. 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. 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. 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. 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. 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. 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. 4 Most Dangerous Words It Couldn’t Happen Here
  • 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. A Better Way Sir Liam Donaldson A humane and life-giving encounter
  • 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
  • 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. 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. Patient Engagement & Education
  • 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. 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. 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. 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. PARTNERSHIP COLLABORATION DIALOGUE = POWERFUL CONVERSATION
  • 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. “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