Serious Incident Investigations. Elaine Spencer Serious incident Investigator

Transcription

1 Serious Incident Investigations Elaine Spencer Serious incident Investigator

2 Serious Incident Investigations: the brief Identifying serious incidents that require investigation Root cause analysis methodology Interviewing staff Liaising with patients and families Being open

3 Serious Incident Investigations Use a patient story 63 year old Alcohol dependence Peripheral vascular disease Atrial fibrillation

4 Marion s story Found at home by her grandson having fallen. Seen in the ED Admitted to the SSW ECG/ IV Fluids/ potassium replacement/pabrinex Review by Community Rapid Response Service in the morning

5 Marion s story Stable overnight Sudden deterioration at 6am Blood pressure un-recordable Resuscitation CXR - Upper lobe pneumonia ITU RIP 17.00hrs

6 Identifying Serious Incidents

7 Liaising with patients and families Acknowledgment Apology Explain

8 Being open Contact with daughter offer a meeting to gain their views, concerns, queries and questions Explained what was known at the time Met at opening of inquest Maintained telephone contact throughout investigation Offered meeting once the investigation was complete

9 RCA (Tom Jones methodology) Date and Time Event Policy/Protocol in use Questions

10 Interview process Opening the interview establish rapport Explain aims of interview (your memory of events) Initiate free rapport (take yourself back..) good listener no interruptions (disrupts interviewees memory sequence) Ask to report everything Clarify and summarise Closure what happens now

11 Reason s Swiss cheese model Levels of defence LATENT CONDITIONS : poor design, procedures, management decisions etc.. Patient Safety Incident ACTIVE ERRORS

12 People, people, people Image of people

13 Cognition Analytical cognitive processes Conscious Mental effort Deliberate Rule-based Takes time Flexible

14 Cognition Automatic cognitive processes Tacit knowledge Short-cuts learned from experience Rules of thumb Selected by pattern recognition Its fast, requires little mental effort It s the default process

15 Cognitive biases

16 Cognition Switch between these two processes What conditions affect cognition? Interruptions Emotion Tiredness & fatigue

17 The investigator retrospective outsider From the perspective of the outside and hindsight, the entire sequence of events is exposed the triggering conditions, its various twists and turns, the outcome, and the true nature of circumstances surrounding the route to trouble. This contrasts fundamentally with the point of view of people who were inside the situation as it unfolded around them. To them, the outcome was not known, nor the entirety of surrounding circumstances. They contributed to the direction of the sequence of events on the basis of what they saw and understood to be the case on the inside of the evolving situation. The challenge for an investigator..is to see how other people s decisions were likely nothing more than continuous behaviour reinforced by their current understanding of the situation, confirmed by the cues they were focusing on, and reaffirmed by their expectations of how things would develop Real insight comes from seeing the world through the eyes of the protagonists at the time. S Dekker Reconstructing human contributions to accidents: the new view on error and performance (2002)

18 Effective Learning - Hierarchy of effectiveness Stronger Actions Change cultural approach Architectural / physical plant or equipment changes Standardise and usability testing of equipment or care plans Simplify the process and remove unnecessary steps Degree of difficulty Moderately Strong Actions Effective use of skill mix Eliminate look and sound-a-likes Eliminate / reduce distractions Checklist / cognitive aids Weaker Actions Double checks Warnings and labels New procedure / policy Re-Training focused on an individual From: C Lee, K Hirschler. How to make the most of actions and outcomes

19 Being open Contacted to meet once report finalised Declined Sent report by post as requested Expectation Support

20 Duty of candour

21 What should be reported? Anything unintended or unexpected if it causes or is expected to cause: Death or severe harm Moderate harm Prolonged psychological harm (28 days continuous)

22 Duty of Candour Moderate Harm Harm that requires a moderate increase in treatment AND Significant but not permanent harm Criminal sanctions Contractual and statutory duties apply to the organisation

23 Duty of Candour Notify the relevant person (as soon as reasonably practicable) Notification given in person Provide an account of the facts Apology Written record Advise on further enquiries

24 Duty of Candour Details in regulation 20 (3) Contractual duty to notify within 10 days Less scope for judgement and review Prompt decision making

25 The brief. Identifying serious incidents that require investigation Root cause analysis methodology Interviewing staff Liaising with patients and families Being open Duty of candour (moderate harm)

26 Thank you Any questions?