1. Errors, Clinical Governance and
Patient Safety
Dr R Krishnan
Consultant Paediatric Nephrologist
University Hospital of Wales

2. Objective of this presentation
• Overall introduction to Clinical Governance
• Differences between errors and incidents
• Steps to Patient safety
• Patient safety agencies
• How to prevent incidents

3. • The potential for error presents a constant challenge in the safe
delivery of health services. When things go wrong, or are narrowly
avoided, there is an opportunity for patients, teams and
organisations to identify why it happened and act to improve patient
safety
• The UK is a leader in patient safety as we reflected and learned from
the catastrophic errors we have made in the past
e. g Injection of Vinca Alkaloid intra spinally – Wayne Jowett
Why is this important?

4. • Incident: an unintended or unexpected event that led to
patient/staff harm, including death, disability, injury, disease
or suffering
• Error: a slip, lapse, mistake or violation that leads to an
incident
• Near-miss: any situation that could have resulted in an
incident, but did not due to either chance or intervention.
Errors and Incident

5. • The potential for error presents a constant challenge in the safe
delivery of health services. When things go wrong, or are narrowly
avoided, there is an opportunity for patients, teams and
organisations to identify why it happened and act to improve patient
safety
• What went wrong?
• Where it happened?
• Why it happened?

6. • NPSA lead and contribute to improved, safe patient care by informing, supporting and
influencing organisations and people working in the health sector.
• Aims to reduce risks to patients receiving NHS care and improve safety.
NPSA works the National Reporting and Learning System (NRLS)
Patient Safety Division collects confidential reports of patient safety incidents
Clinicians and safety experts analyse these reports
Identify common risks and opportunities to improve patient safety.
National Patient Safety Agency

7. Build a safety culture
Lead and support your staff
Integrate your risk management activity
Promote reporting
Involve and communicate with patients and the public
Learn and share safety lessons
Implement solutions to prevent harm
Seven steps to patient safety

8. • Three types of incidents should be reported:
Incidents that have occurred All incidents need to be reported including:
– suicides and deaths in health premises require to be reported
– reportable diseases such as chickenpox tuberculosis and HIV
– injuries to staff at work
– minor incidents (can build up to a major incident)
Incidents that have been prevented (also known as near misses) Near-miss
reporting gives you information on:
– weakness in the health care system
– recovery processes that can prevent adverse events
Incidents that might happen
– delays in equipment repair
– risk assessment should identify risks
– staff may be aware of variations in practice.
Incidents

9. • Most incidents are as a result of failures in the
systems and processes related to treatment and
services:
• Errors are shaped and provoked by systems
• Similar incidents occur regardless of the individuals
involved
• Similar circumstances cause the same incidents to
occur.
Why do incidents happen?

10. Why do incidents happen?
Human factors such as:
• level of skill
• understanding of rules and routines
• knowledge and familiarity with the task
• Most systems include number of defensive layers to safeguard
patients and staff:
• Defences (alarms, layers of access, automatic shutdowns, etc)
• Barriers (locked cupboards, removal of types of medication,
effective labelling)
• safeguards (pharmacy sign-out, double checking with colleague

11. Why do incidents happen?
James Reason Swiss Cheese Model BMJ 2000
Reason suggests that the holes in the defences are a result
of:
• Active failures: unsafe acts committed by people who
are in direct contact with the patient or system. They
take a variety of forms: slips, lapses, fumbles, mistakes,
and procedural violations. Active failures have a direct
and usually short lived impact on the integrity of the
defences.

12. James Reason Swiss Cheese Model BMJ 2000
Reason suggests that the holes in the defences are a result of:
• Latent conditions: potential for things to go wrong within the
system due to the way it is designed or decisions made by
management. Latent conditions create a context for two of
effects to occur:
• Error provoking conditions for example understaffing, inadequate
equipment, and fatigue
• Weaknesses or holes in the defences such as persistant non-
compliance with procedures (shortcuts) and design deficiencies
Why do incidents happen?

13. • Risk assessment
• Root cause analysis
• Significant event analysis
• Incident decision tree
•What happened?
•How it happened?
•Why it happened?
•What happened?
•Why did it happen?
•What has been learned?
•What has been changed?
How to analyse Incidents

14. • Health services are held accountable for the safety, quality and
effectiveness of clinical care delivered to patients
• Statutory requirement
• CG is achieved by co-ordinating three interlinking strands of work:
– Robust national and local systems and structures that help identify,
implement and report on quality improvement
– Quality improvement work involving health care staff, patients and the
public
– Establishing a supportive, inclusive learning culture for improvement
Clinical Governance

15. The three important components of CG are
• Clinical effectiveness activities including audit and redesign
• Risk management including patient safety
• Patient focus and public involvement
Clinical effectiveness can be measured by using
– evidence-based practice
– clinical or medical audit
– guidelines
– outcome measures
Clinical Governance

16. What does it mean?
• Thinking critically about what you do in your job
• Using the evidence to improve what you do
• Involving patients in decisions about their care
• Developing your skills
• Working as a team to make improvements
• Preventing that error from happening again
• Learning lessons from experience and good practice elsewhere and not reinventing the
wheel
• Knowing how to use quality improvement processes and structures to achieve results
• Involving patients and carers in improving services
• Taking an active part in improving the health service for patients
Clinical Governance

17. • Research from America, Australia and the UK indicates that around 10% of
patient contacts result in harm to patients or staff. (IoM 1999, Dept of Health
2000). It is estimated that half of these harmful or adverse incidents are
preventable. The physical and emotional consequences of an incident can be
significant for patients, staff and carers. Adverse incidents also increase costs
to the NHS for additional treatment, claims and litigation.
• Clinical incidents and near-misses, where there is no harm to the patient,
highlight the need for appropriate action to be taken to reduce or manage
risks.
• Adverse incidents are estimated to cost the UK NHS around £2 billion a year
with a further £1 billion attributed to healthcare acquired infection.
Clinical Governance

18. • A hazard is a source of potential harm or situation with the potential
to cause loss, injury or ill-health.
• A risk is the likelihood that harm to a person, service, premises or
organisation will be realised as a result of a hazard.
• An error is a slip, lapse, mistake or violation that leads to an incident.
• An incident is any event or circumstances that could have or did lead
to harm, loss or damage to people, property, environment or
reputation.

19. • Managing risk is about having a system in place that will allow you
to:
• Identify, assess and measure risks
• Compile a record or register of risks so colleagues know what has
been identified
• Decide how to manage the risk
• Take action to manage the risk
• Tell others what you have done
• Review and monitor risks regularly

20. • Communicate and consult: Who will need to know about and be involved at each stage
of the risk management process?
• Establish the context: How will you assess and analyse the risk? What are the criteria
you will use to judge the likelihood and consequences of risk?
• Identify risks: What could stop you achieving your objectives and outcomes?
• Analyse risks: Are our existing risk controls working and what are the potential
consequences of risks happening
• Evaluate risks: What is the balance between potential benefits and adverse outcomes of
managing these risks?
• Treat risks: How can we develop and implement specific cost-effective strategies to
increase benefits and reduce potential costs?
• Monitor and review: Are we achieving the right outcomes and how do we know?

21. • Gentle Introduction into Errors, incidents and Clinical
Governance
• Covered different types of errors, incidents and also other
different terminologies
• Role of NPSA
• Reporting incidents is everyone’s responsibility
Summary