1 00:00:10,000 --> 00:00:18,880 Welcome to the first one of the new year, and it's great to see great turnout, and these are often linked also to the cross, to the church. 2 00:00:18,880 --> 00:00:24,100 I'm not sure if that's going on today or not, but anyway, it's great pleasure to introduce Helen, 3 00:00:24,100 --> 00:00:28,870 who many of you know, consultant anaesthetist of Oxford since 2001, 4 00:00:28,870 --> 00:00:32,890 senior clinical research fellow in the Department of Clinical Neurosciences at the 5 00:00:32,890 --> 00:00:43,360 University and director of the Oxford University's Stimulation Centre and Simulation Centre. 6 00:00:43,360 --> 00:00:49,030 I beg your pardon. Just checking that you are all the way. 7 00:00:49,030 --> 00:00:56,740 She is current executive member and immediate past president of the Association for a simulated practise in health care. 8 00:00:56,740 --> 00:01:00,890 We'll put that down now. Thank you very much, David. Thank you. 9 00:01:00,890 --> 00:01:05,300 It's really nice to be here and to start on such a light-hearted note. 10 00:01:05,300 --> 00:01:12,730 I'm going to be talking about something I feel is quite serious, but I think Peter and I feel really passionately about this and when. 11 00:01:12,730 --> 00:01:16,630 Back in 2013, when we formed the Patient Safety Academy, 12 00:01:16,630 --> 00:01:24,130 it was really the first thing we started talking about as a as a potential project across the region. 13 00:01:24,130 --> 00:01:30,370 And so we began with the idea that we would teach some incident analysis more generally and how one does it, 14 00:01:30,370 --> 00:01:37,900 how one deconstructs incidents and thinks holistically about what's happened rather than the more, 15 00:01:37,900 --> 00:01:44,170 dare I say, ill formed root cause analysis process that the NHS advocates. 16 00:01:44,170 --> 00:01:50,620 So what I'm going to talk about this morning is that human factors approach to instant analysis. 17 00:01:50,620 --> 00:01:54,310 I'm going to talk a bit about the background about why we should be doing this. 18 00:01:54,310 --> 00:02:04,240 I hope it's pretty obvious. And then explain this external review project that we were involved in because I still have hope that it will restart. 19 00:02:04,240 --> 00:02:07,900 And, you know, we'll get it going again across the region and perhaps nationally. 20 00:02:07,900 --> 00:02:11,860 There's definitely interest from from many national bodies. So that's my hope. 21 00:02:11,860 --> 00:02:16,060 And then finally, I can you see, I've put lock slips in little letters. 22 00:02:16,060 --> 00:02:18,620 Yeah, because I didn't want to freak you all out. 23 00:02:18,620 --> 00:02:26,020 It's actually something again that Alastair and I are working really hard on with Rachel and Helen in this big group. 24 00:02:26,020 --> 00:02:30,400 But I think I would really like to emphasise why it is. 25 00:02:30,400 --> 00:02:35,080 That checklist can support safe practise, and I'll go into that in a little bit of detail at the end. 26 00:02:35,080 --> 00:02:37,630 I'm going to make sure I get you all out of here on time as well. 27 00:02:37,630 --> 00:02:41,890 I absolutely promise because I know one of my friends in here has a hair appointment, 28 00:02:41,890 --> 00:02:49,300 and that's particularly important as you're going to kill me for saying it. OK, so why? 29 00:02:49,300 --> 00:02:52,330 I love this figure from Robyn Furness paper, 30 00:02:52,330 --> 00:03:01,900 where he suggests that health care is rather more akin to bungee jumping than to a flight on British Airways. 31 00:03:01,900 --> 00:03:06,940 And unfortunately, I think that's still the case. 32 00:03:06,940 --> 00:03:16,240 If we look at the data. The very first red flag that was waved was back in 91 in the New England Journal from Lucien Leak's Group, 33 00:03:16,240 --> 00:03:25,330 and they did an exhaustive retrospective review of over 30000 sets of case case notes from 200+ acute 34 00:03:25,330 --> 00:03:34,830 care settings and discovered that one in 200 patients would die as a direct result of an adverse event. 35 00:03:34,830 --> 00:03:40,830 And so at that time, a lot of hands were thrown up in horror. You know, how very dare you suggest that we're harming our patients? 36 00:03:40,830 --> 00:03:43,740 That was not what they were suggesting at all. 37 00:03:43,740 --> 00:03:50,070 They were suggesting they were there were system wide problems that were leading to errors in health care. 38 00:03:50,070 --> 00:04:00,250 And then after that? There are an enormous number of kind of meta papers that were delivered from developed health care systems around the world, 39 00:04:00,250 --> 00:04:03,850 including our own Sir Charles Vincent wrote this one. 40 00:04:03,850 --> 00:04:09,940 And he actually looked into in addition to the number of deaths that would result from adverse events, he said. 41 00:04:09,940 --> 00:04:14,470 Look, if if the if the patient doesn't die as a result of this adverse event, 42 00:04:14,470 --> 00:04:20,170 if we just kind of harm them a little bit, how much longer are they going to stay in hospital? 43 00:04:20,170 --> 00:04:24,580 And he calculated that it was on average, another eight days. 44 00:04:24,580 --> 00:04:31,710 And so the cost to the NHS at that stage was over a billion pounds, and you can see that that's quite a long time ago now. 45 00:04:31,710 --> 00:04:41,010 So unsafe care is expensive, but actually, where have we gone since all this evidence has been highlighted? 46 00:04:41,010 --> 00:04:50,340 And unfortunately, it would appear that certainly if you believe what most Amachree is saying, that it's actually underestimated what's going on. 47 00:04:50,340 --> 00:05:00,120 And I think that's probably because an awful lot more evidence has come out about how these things happen in complex, fairly chaotic systems of care. 48 00:05:00,120 --> 00:05:08,250 So whilst there are pockets of excellent activity, I think I would I would agree with Charles when he says that, 49 00:05:08,250 --> 00:05:18,490 you know, all in all, what we're not seeing is widespread, sustainable change to reduce error. 50 00:05:18,490 --> 00:05:26,320 So I'm a big fan of Demings, and I absolutely agree with wholeheartedly agree with this statement. 51 00:05:26,320 --> 00:05:34,180 It's always about the system in the process, a little bit about the people, but you've got to be looking at systems and processes. 52 00:05:34,180 --> 00:05:42,760 Of course, we do design the systems and processes. And so, you know, it kind of behoves us to be thinking about what we do with them. 53 00:05:42,760 --> 00:05:48,100 So I'm just going to unpack. I don't like, I'm afraid, using the words never event, so I won't. 54 00:05:48,100 --> 00:05:52,000 This is the American nomenclature. They call them sentinel events. 55 00:05:52,000 --> 00:05:59,800 And this is an investigation that I did fairly recently in dermatology, and I picked it because it is a surgical problem. 56 00:05:59,800 --> 00:06:06,940 OK. But in a different culture. And that's what interested me so much about this particular event. 57 00:06:06,940 --> 00:06:14,390 So this is a team that has a very busy, busy outpatient department and a patient came in for the removal of a skin lesion. 58 00:06:14,390 --> 00:06:20,690 They do a lot of this, if the nation wasn't marked, there was no computer screen and theatre for them to confirm it. 59 00:06:20,690 --> 00:06:26,180 And it was hard for the patient to confirm where the lesion was because it was on his back. 60 00:06:26,180 --> 00:06:31,760 The WHO time up didn't involve the nurse. She was busy unpacking the kit and then they removed the wrong lesion. 61 00:06:31,760 --> 00:06:41,660 I mean, what a bunch of idiots. Until actually you realise that it always looks more like this. 62 00:06:41,660 --> 00:06:54,860 So many other influencing factors around organisational issues, culture, team working and communication tools and technology, 63 00:06:54,860 --> 00:07:01,010 the environment and so forth, and there's often a little bit of bad luck as there was in this case. 64 00:07:01,010 --> 00:07:10,370 And if we don't unpack them, then the result is that we usually think that what a bunch of idiots. 65 00:07:10,370 --> 00:07:17,720 So I quite like using these very straightforward tools to think about how errors occur, and I don't we should read this. 66 00:07:17,720 --> 00:07:23,210 I just want you to see that under the people column, there's only a little bit of information. 67 00:07:23,210 --> 00:07:28,760 All of it sets in culture, equipment and task and system. OK. 68 00:07:28,760 --> 00:07:31,610 Not to do with the people. 69 00:07:31,610 --> 00:07:41,360 Now the paradigm shift, as has happened in high reliability organisations like civil aviation, nuclear power, the railways, those kind of groups. 70 00:07:41,360 --> 00:07:48,560 Is it instead of saying who did this? They say, How did this happen? 71 00:07:48,560 --> 00:07:54,490 And so instead of seeing the human being is the cause of failure and error, they say, look. 72 00:07:54,490 --> 00:07:56,810 Because, you know, there may be an aspect of human error here, 73 00:07:56,810 --> 00:08:05,400 but it's likely that that was caused by other wider systemic vulnerabilities that we haven't understood clearly. 74 00:08:05,400 --> 00:08:08,670 And when you're describing what happens in an incident a bit like that, well, 75 00:08:08,670 --> 00:08:13,860 they took the patient comes in, didn't market, didn't do the WHO properly took the wrong vision of. 76 00:08:13,860 --> 00:08:19,060 That's quite a satisfying way of describing the error. 77 00:08:19,060 --> 00:08:29,340 But what it doesn't do is explain why it made sense for the individual or the team involved at the time to do what they did. 78 00:08:29,340 --> 00:08:39,240 It's meaningless. And I don't know how many of you have had an email from On High, which says, Now listen, everybody. 79 00:08:39,240 --> 00:08:43,860 Mrs. Smith got 10 times a dose of insulin post-operatively the other day on Ward 38. 80 00:08:43,860 --> 00:08:48,530 I want you all to be a bit more careful, please. Yours sincerely. 81 00:08:48,530 --> 00:08:54,890 And not helpful. That's never, ever going to help, just makes people cross. 82 00:08:54,890 --> 00:08:57,110 It is only. 83 00:08:57,110 --> 00:09:07,370 Why always being aware of the potential vulnerabilities within a system that we're going to learn and adapt if we're always on the defensive? 84 00:09:07,370 --> 00:09:11,510 We're never going to be able to say, Right, okay, everyone, let's work together on this. 85 00:09:11,510 --> 00:09:16,590 Let's trust each other and fix it. 86 00:09:16,590 --> 00:09:27,540 So this report that was back in back in 15, it was released in the select committee highlighted quite nicely the fundamental flaws. 87 00:09:27,540 --> 00:09:34,410 Frankly, what it says is that instant analysis within health care is not fit for purpose. 88 00:09:34,410 --> 00:09:43,060 For many reasons. And unfortunately, it is destructive to both staff and families. 89 00:09:43,060 --> 00:09:49,900 And so in 2017, the Healthcare Safety Investigation Branch was born each step along the lines of the AAIB, 90 00:09:49,900 --> 00:09:53,830 although of course, in health care we don't have black boxes which are sacrosanct. 91 00:09:53,830 --> 00:10:01,660 We have a duty of candour, so we do have to explain what's gone wrong to the families and carers and so forth. 92 00:10:01,660 --> 00:10:10,890 And that's important, but it does mean that that information is then out there to be judged by whoever wishes to judge it. 93 00:10:10,890 --> 00:10:21,840 So what we thought was that it would be good to work across our region because we're a pretty compact, fairly geographically close group of hospitals, 94 00:10:21,840 --> 00:10:29,130 acute care settings and see if we could think about developing an external review process where groups of investigators from 95 00:10:29,130 --> 00:10:37,080 different trusts around Thames Valley would review each other's incidents or support each other in investigating incidents. 96 00:10:37,080 --> 00:10:44,850 So we revised educational materials and we thought, Well, you know, how are we going to think about the data? 97 00:10:44,850 --> 00:10:49,770 And we realised that it would be quite a lot of cool data, but a little bit of quantitative evidence. 98 00:10:49,770 --> 00:10:54,570 Anyway, we what we found, perhaps not surprisingly, 99 00:10:54,570 --> 00:11:01,940 that there was a clear lack of human factor skills across the board in the trusts in Thames Valley. 100 00:11:01,940 --> 00:11:10,380 And there was absolutely a lack of standardisation of approach to instant analysis, right down to the fact that all the forms are different. 101 00:11:10,380 --> 00:11:17,280 Wherever you go, there was a huge variability in level of support for people who were investigating and time that was given a 102 00:11:17,280 --> 00:11:23,550 variability in the way decisions were made about what level of investigation was necessary for particular incidents. 103 00:11:23,550 --> 00:11:24,930 And you know, in this organisation, 104 00:11:24,930 --> 00:11:35,740 we have a meeting every Thursday morning at which we discuss what level of investigation and a consensus is achieved. 105 00:11:35,740 --> 00:11:39,760 So there are quite a lot of conflicts of interest, of course, you know, there is no no, 106 00:11:39,760 --> 00:11:44,650 no high reliability organisation investigates its own naval like we do. 107 00:11:44,650 --> 00:11:50,650 I mean, it's completely bonkers. You know, you're asked to investigate an incident that has happened in your trust, 108 00:11:50,650 --> 00:11:55,450 often within an area where, you know, you know, people, they'll be your friends. 109 00:11:55,450 --> 00:12:00,760 And so it's it's impossible for the for no bias to exist. 110 00:12:00,760 --> 00:12:07,970 Well, that's impossible anyway. But it's far less likely when you work in the organisation, you pay by them. 111 00:12:07,970 --> 00:12:14,030 And of course, what was really interesting and perhaps most challenging was that persuading medical directors around the region that 112 00:12:14,030 --> 00:12:21,870 we wouldn't be displaying their dirty laundry for everyone to see was a huge challenge really was very difficult, 113 00:12:21,870 --> 00:12:29,210 quite surprisingly difficult. And we had to develop an emoji to to to reassure them. 114 00:12:29,210 --> 00:12:38,990 So we set up this project, we trained some trainers, and what we wanted to do was support them in increasing the openness and transparency, 115 00:12:38,990 --> 00:12:46,730 the sharing of learning around the region to develop a consistent way of investigating serious incidents in health care. 116 00:12:46,730 --> 00:12:48,260 And obviously to enhance. 117 00:12:48,260 --> 00:12:54,470 Hopefully, the knock on effect will be enhancing the quality of other internal investigations that were going on in the organisation. 118 00:12:54,470 --> 00:12:58,010 So we engaged with medical nursing directors. We designed a template, 119 00:12:58,010 --> 00:13:04,820 the new template for the investigations delivered the training and then we compared the results 120 00:13:04,820 --> 00:13:11,880 of internal investigations against the results of external human factors led investigations. 121 00:13:11,880 --> 00:13:16,950 So we had a couple of investigations for trust, which was what we were hoping for. 122 00:13:16,950 --> 00:13:26,700 And all of the investigators were supported by human factors, expertise from us in the Patient Safety Academy. 123 00:13:26,700 --> 00:13:36,630 Within the training, we wanted to explore two straightforward models of human factors analysis to support them in doing this. 124 00:13:36,630 --> 00:13:41,400 And these were the two that we picked, but we also explained that there were others out there. 125 00:13:41,400 --> 00:13:46,110 And frankly, you just choose the one that suits you best. 126 00:13:46,110 --> 00:13:52,320 I think both of these are good for me was fine. They will have the little nuances, but that was what we were teaching. 127 00:13:52,320 --> 00:13:59,460 Use these models as a framework for thinking about what's happened in this incident. 128 00:13:59,460 --> 00:14:08,610 So the barriers I've already mentioned, the reluctance to take part in the indemnity issues, the logistic difficulties were also quite substantial. 129 00:14:08,610 --> 00:14:17,970 Sharing information across, you know, regions. So if you if you've got investigators from Milton Keynes coming here to look at one of our incidents, 130 00:14:17,970 --> 00:14:23,700 it was it was quite challenging getting the time and aligning everyone and data reports. 131 00:14:23,700 --> 00:14:27,480 Anyone they wish to speak to these kind of things was difficult. 132 00:14:27,480 --> 00:14:32,010 And then, of course, completing the timely report because you've got 60 days, for example, 133 00:14:32,010 --> 00:14:39,950 from the point of a of a of a sentinel event occurring 60 working days to completion of the report. 134 00:14:39,950 --> 00:14:48,740 So I'm going to give you a couple of examples just to show you how this worked. So this is a more surgical example of surgical examples, actually, 135 00:14:48,740 --> 00:14:54,560 but this is a 64 year old male with lung cancer, complex problems, complex co-morbidities. 136 00:14:54,560 --> 00:15:00,050 He'd had previous thoracic surgery and he came in breathless. 137 00:15:00,050 --> 00:15:05,840 So he was admitted under the medicks. OK, that seems sensible. 138 00:15:05,840 --> 00:15:09,830 They discovered an emergency infusion on his X-ray. 139 00:15:09,830 --> 00:15:14,060 Quite a substantial effusion, and he had quite bad chest pain. 140 00:15:14,060 --> 00:15:22,880 He'd been in and out of the hospital since his surgery with youkai and peter thromboembolic complications in the past as well. 141 00:15:22,880 --> 00:15:27,830 But this was this was a complicated patient, as I say, who had previous thoracic surgery. 142 00:15:27,830 --> 00:15:34,460 And unfortunately, there were delays in decisions about what to do with this big effusion about how they were going to drain it because of course, 143 00:15:34,460 --> 00:15:43,240 he was anticoagulated. But what no one did was think, well, we should involve the thoracic surgeons that took his lobe out and say, 144 00:15:43,240 --> 00:15:48,300 you know, can you give us some advice here? How do we how do we do this safely? 145 00:15:48,300 --> 00:15:53,340 And of course, then there's a delay and confusion about, do we stop the prophylaxis, do we restart it? 146 00:15:53,340 --> 00:16:00,270 Do we stop it? And he ends up with a. So I don't want to go into this in too much detail. 147 00:16:00,270 --> 00:16:06,990 Suffice it to say that the findings of the internal report focussed only on the fact that 148 00:16:06,990 --> 00:16:12,060 the anticoagulation was withheld inappropriately and it wasn't restarted appropriately. 149 00:16:12,060 --> 00:16:18,180 And of course, that that was a problem. But what it didn't explore was all the other things that you can see in the 150 00:16:18,180 --> 00:16:24,140 external report around systems problems around communication between teams. 151 00:16:24,140 --> 00:16:32,530 About supporting each other and other EPR interface issues that were that were a problem. 152 00:16:32,530 --> 00:16:34,750 And when you look at the recommendations, I mean, 153 00:16:34,750 --> 00:16:44,510 to speak a little bit about recommendations as well and how we design those two things which really just revolved around prescribing. 154 00:16:44,510 --> 00:16:50,180 Whereas on the external size, you're looking at thinking about the system and the pathway. 155 00:16:50,180 --> 00:17:03,470 Thinking about joined up working patterns. And and obviously a bit about the system and process of prescribing, but perhaps in a little more detail. 156 00:17:03,470 --> 00:17:07,910 So this next story is of a complicated pregnancy. 157 00:17:07,910 --> 00:17:16,160 A woman in her first pregnancy who comes into the labour ward and she has premature rupture of membranes. 158 00:17:16,160 --> 00:17:22,970 She's had multiple problems in the pregnancy, including intrauterine growth retardation, severe nausea and vomiting. 159 00:17:22,970 --> 00:17:28,400 She got Group B strep and it's breech. So you know, this is problematic. 160 00:17:28,400 --> 00:17:36,530 And unfortunately, the outcome was a premature delivery by caesarean section and the child did not survive. 161 00:17:36,530 --> 00:17:47,120 So when we think about the findings from this incident and we look at what's happened again, I don't really want you to read all of the words here. 162 00:17:47,120 --> 00:17:54,770 I'm just saying, look at the difference between the amount and the type of findings. 163 00:17:54,770 --> 00:17:58,710 So there's a lot more around system and so forth in the external report. 164 00:17:58,710 --> 00:18:05,830 But just look at the number of times that a finger is pointed at the junior midwife. 165 00:18:05,830 --> 00:18:17,000 On the internal side goes back to exactly what I was saying about this paradigm shift, not who did this, but how did it happen? 166 00:18:17,000 --> 00:18:24,350 And then when you think about recommendations, again, more on the internals on the external side, about missed opportunities, 167 00:18:24,350 --> 00:18:31,910 about pathways, procedures and processes and so forth, and some some idea about what kind of training is good. 168 00:18:31,910 --> 00:18:37,160 Let's understand what the training is, and let's devise a package that's far more productive. 169 00:18:37,160 --> 00:18:42,680 And on the internal side, you'll say you'll say, let's have two meetings, a couple of lectures in a reflective account. 170 00:18:42,680 --> 00:18:49,430 Thank you very much. Tickety boo. Bobbins never going to work. 171 00:18:49,430 --> 00:18:59,580 So I hope it's clear the difference is when you use a far more holistic approach to thinking about these kind of serious incidents. 172 00:18:59,580 --> 00:19:02,340 So the sort of feedback we got was obviously strongly positive. 173 00:19:02,340 --> 00:19:09,780 What we discovered was a lot of support was needed from us in the PSA to help people come to these sorts of conclusions. 174 00:19:09,780 --> 00:19:15,900 But we saw richer reports and also recognised that actually the clinical expertise 175 00:19:15,900 --> 00:19:21,330 on the local site and from the investigation team is also very important. 176 00:19:21,330 --> 00:19:26,270 So just having that little bit of contextual knowledge is vital. 177 00:19:26,270 --> 00:19:31,520 But inertia remains a major problem. The logistics were an issue. 178 00:19:31,520 --> 00:19:42,560 And of course, if we're going to do this, it will require resource and you all know about the workforce issues in the NHS at the moment. 179 00:19:42,560 --> 00:19:45,650 So next steps, we obviously want to take this further, 180 00:19:45,650 --> 00:19:52,220 and the long term vision is that we would work with each step and other groups to develop a national network of people with 181 00:19:52,220 --> 00:20:00,020 these kind of skills that would be able to support their regions in the delivery of higher quality investigations and, 182 00:20:00,020 --> 00:20:05,180 most importantly, recommendations for serious incidents. 183 00:20:05,180 --> 00:20:09,920 So I'm now going to think about recommendations and focus just on one area and that checklist, right? 184 00:20:09,920 --> 00:20:16,060 Cognitive aids. Checklist is a form of cognitive aid. 185 00:20:16,060 --> 00:20:20,980 When you think about recommendations, this is from the Canadian framework, for instance, analysis, which is it's a really good document. 186 00:20:20,980 --> 00:20:25,720 It's free to download if you're interested, it's and it's on the. 187 00:20:25,720 --> 00:20:32,050 The way you can categorise and we can think about them is, you know, how likely is it that this is going to make a difference? 188 00:20:32,050 --> 00:20:35,980 And you can see the sorts of things, the strong things, redesign of equipment, 189 00:20:35,980 --> 00:20:41,290 all these sorts of physical interventions to try and prevent things happening a far 190 00:20:41,290 --> 00:20:47,260 more powerful than procedural interventions than telling people how to do it better. 191 00:20:47,260 --> 00:20:54,440 It's far better to provide them with something that will help them to do it better than to say, just think a bit harder or be more careful. 192 00:20:54,440 --> 00:21:02,330 OK. I have a little bit of a problem with training being weak, I'm very passionate proponent of high quality education, 193 00:21:02,330 --> 00:21:06,830 and I think the problem with training is exactly what you saw in the previous incident. 194 00:21:06,830 --> 00:21:13,820 Give them a lecture. Tell them to write a reflective report by the boom by typing. 195 00:21:13,820 --> 00:21:21,110 Rubbish. It needs to be low dose, high frequency interventions, particularly in the kind of environments we work in. 196 00:21:21,110 --> 00:21:25,550 So the sorts of team training that I'm talking about mean we stop for an hour, 197 00:21:25,550 --> 00:21:31,160 you know, or the list goes down in the afternoon, let's run an anaphylaxis. Let's run our malignant hypothermia, blah blah blah. 198 00:21:31,160 --> 00:21:38,160 A massive haemorrhage, whatever. It's got to be that kind of style, but it's challenging time wise. 199 00:21:38,160 --> 00:21:42,810 So those are the way we think about recommendations, but then of course, you do have to consider cost, OK? 200 00:21:42,810 --> 00:21:45,810 So you've got your week and you strong, but then you think, Well, how expensive is it? 201 00:21:45,810 --> 00:21:48,990 So just to give you an example of what I mean by that, obviously, 202 00:21:48,990 --> 00:21:54,090 I would like to rebuild cities and fix some of the problems we face, certainly in the John Ratcliffe. 203 00:21:54,090 --> 00:22:00,690 But that's prohibitively expensive. Whereas you look at give a lecture, great, that's dead cheap. 204 00:22:00,690 --> 00:22:05,590 But as again, I say rubbish, I'm not going to work. 205 00:22:05,590 --> 00:22:15,660 OK. So the evidence for checklists, particularly in the areas we work in, theatres and procedural environments, is very clear. 206 00:22:15,660 --> 00:22:23,740 They are useful cognitive aids, but of course you have to believe in them and you have to use them properly. 207 00:22:23,740 --> 00:22:28,600 And, you know, over the years, it has become apparent that where it is done properly, 208 00:22:28,600 --> 00:22:33,650 where they are co-designed by the teams that are going to use them so that they are fit for purpose. 209 00:22:33,650 --> 00:22:40,430 Well, they absolutely. Work for the contextual environment in which they're being used. 210 00:22:40,430 --> 00:22:52,270 Great. And I think this this latest review from the Bee Gees is a really nice read, if you want the kind of two page overview of why they work. 211 00:22:52,270 --> 00:23:00,040 Just go to that. It's, of course, in 2015, this document came out that steps. 212 00:23:00,040 --> 00:23:08,470 Crikey, I think, Alison, I've been blinking dreaming about these, just so the mantra is standardised harmonise, educate. 213 00:23:08,470 --> 00:23:12,880 OK. The standardised thing is really important. 214 00:23:12,880 --> 00:23:21,940 I'm a little bit frankly bemused by the fact that we have nuts, chips, but then they said, Right, so we're a national health service. 215 00:23:21,940 --> 00:23:29,050 Ideally, the way I take off a lesion in Oxford should be the way they take off a lesion in Dundee. 216 00:23:29,050 --> 00:23:34,600 OK. Why would it be different? Why would the procedure be different nuances? But why would the procedure be different? 217 00:23:34,600 --> 00:23:42,340 So why do I therefore need Loch Lips, local safe surgery and invasive procedures guidance? 218 00:23:42,340 --> 00:23:46,360 Why? You know, correct me if I'm wrong, but there you go. 219 00:23:46,360 --> 00:23:48,880 I'm so but, but it is what it is. 220 00:23:48,880 --> 00:23:58,540 So just to go back to the point of this issue, this surgical issue in dermatology, the culture was fascinating around the use of the WHO checklist. 221 00:23:58,540 --> 00:24:08,260 They call themselves dermatological surgeons, which again interested me and then who checklist was to sort of two little questions 222 00:24:08,260 --> 00:24:13,090 like this on a box with tiny little tick boxes that they may or may not bother with. 223 00:24:13,090 --> 00:24:22,950 And the doctor just did that with the patient. Absolutely against the culture that we have in theatres around the use of the show, just interesting. 224 00:24:22,950 --> 00:24:27,550 Because of the way they work, the patterns of work systems and processes are all very different in dermatology, 225 00:24:27,550 --> 00:24:33,340 but they're doing the same things that my colleagues in plastic surgery do on a daily basis in the West Wing. 226 00:24:33,340 --> 00:24:40,710 So why is it so different over that? Interesting. There are lots of reasons, obviously, but anyway, they are amazing. 227 00:24:40,710 --> 00:24:42,810 They have totally bought into this. 228 00:24:42,810 --> 00:24:49,600 They've designed their checklist again, I would argue, you know, should look a bit more like the generic, but these are first steps. 229 00:24:49,600 --> 00:24:54,750 What you don't want to do is put people off and say, Well, no, you can't do it like that. It must be like, this is how we do it in theatres. 230 00:24:54,750 --> 00:24:59,610 You know, that's not helpful. If you're going to enact a cultural change, you must get buy in. 231 00:24:59,610 --> 00:25:03,720 And so they've designed this and we use simulation to support them in embedding it. 232 00:25:03,720 --> 00:25:08,760 And they recognised actually that the question they were asking about antibiotics, which they don't use that often. 233 00:25:08,760 --> 00:25:14,970 But when they do, obviously they need to ask about it early. They need to say, we're going to get these in if they're going to be effective. 234 00:25:14,970 --> 00:25:19,140 And they were asking the question just at night, asking if you like, OK, that's not going to work. 235 00:25:19,140 --> 00:25:23,950 You need to bring that into the into the briefing. And they didn't do a morning briefing like we all do. 236 00:25:23,950 --> 00:25:29,610 It was none of that. Let me just crack on fascinating. 237 00:25:29,610 --> 00:25:32,640 But as I say, they're fantastic. They are a brilliant team. 238 00:25:32,640 --> 00:25:38,880 All 57 of the staff that were available that work in outpatients came to the simulation session that we ran. 239 00:25:38,880 --> 00:25:41,760 Then there's our area of practise stop before you block. 240 00:25:41,760 --> 00:25:50,640 A standard operating procedure, when used appropriately, can support safe practise for me in delivering the blocks that I do. 241 00:25:50,640 --> 00:25:58,790 It's not. Nothing is ever going to be perfect. This isn't Bullet-Proof. But it is designed to support me. 242 00:25:58,790 --> 00:26:07,280 And then our surgical checklist, so we've been working in the safe surgery and Invasive Procedures Group for it's been since about 2017, 243 00:26:07,280 --> 00:26:17,180 but Alison, I began just about a year ago and this was this was our surgical safety checklist, but there were issues with its design. 244 00:26:17,180 --> 00:26:21,050 It had been out since 2013 and it was time for a revision. 245 00:26:21,050 --> 00:26:29,090 So what happened was before we became involved in the group, kind of working group was set up to consider what needed to happen next. 246 00:26:29,090 --> 00:26:34,070 And it was it was a very multi-disciplinary group, entirely appropriately, but there was no human factors input. 247 00:26:34,070 --> 00:26:39,470 And so what they came up with was this. A two page document. 248 00:26:39,470 --> 00:26:44,600 Admittedly, designed for EPR use, primarily, although it would have been paper based at first, 249 00:26:44,600 --> 00:26:54,560 but if I looked at that in cities, you know, on a Monday morning, are we asking all these questions for complete waste of time? 250 00:26:54,560 --> 00:27:01,400 Why is that relevant to what I'm doing in foot and ankle surgery or in max fax nonsense? 251 00:27:01,400 --> 00:27:08,240 So we spent a long time rethinking reworking, and we had an enormous amount of support, probably from many of you in this room, 252 00:27:08,240 --> 00:27:14,600 actually just looking at Ali and a number of others, all of you provided input and guidance on what this should look like. 253 00:27:14,600 --> 00:27:21,680 We know it's not perfect. You know, we tested it in Max Vax Daljit and I worked together on a Tuesday and we tested it a couple of places. 254 00:27:21,680 --> 00:27:25,010 She was very good about it and we tested it and mucked about with it. 255 00:27:25,010 --> 00:27:31,160 And we had some really good input from the team in Max Sparks great input from the gang in orthopaedics. 256 00:27:31,160 --> 00:27:33,530 And then Alister over at the Churchill. 257 00:27:33,530 --> 00:27:39,890 And then lots of information from groups that provided responses to the survey monkey questionnaire that we sent out. 258 00:27:39,890 --> 00:27:41,150 So this is where we're at. 259 00:27:41,150 --> 00:27:47,900 Of course, it's going to be electronic soon, which, as I say, should make this process of iteration far, far more straightforward. 260 00:27:47,900 --> 00:27:51,650 But the key here is we need to standardise people. 261 00:27:51,650 --> 00:27:56,210 Neighbours need to walk from theatre systems that we so I recognise this. I know how to use this, I know how we do. 262 00:27:56,210 --> 00:28:03,880 This co-design is vital. There's no point me imagining how they work in church offices. 263 00:28:03,880 --> 00:28:10,460 You know, I've never done any of the robotic surgery that happens over there. So I suspect there are things that may be important. 264 00:28:10,460 --> 00:28:16,520 Co-design is vital. Get the team that does the work to say, Yeah, that's really not important for us. 265 00:28:16,520 --> 00:28:20,990 We need it to look like this buy-in at all levels top down, bottom up. 266 00:28:20,990 --> 00:28:24,920 There's got to be support time given to people to do this kind of thing, and less is more. 267 00:28:24,920 --> 00:28:32,320 Don't ask too many questions. And then once you've got a checklist, you need to train people how to use it. 268 00:28:32,320 --> 00:28:35,770 It is not intuitive. Most checklists are read. 269 00:28:35,770 --> 00:28:43,430 Do some read, confirm if you're using them as an isolated practitioner, but most of them reduce it to people. 270 00:28:43,430 --> 00:28:47,980 Now in theatres, it's more than that, obviously, but that's the aviation model. 271 00:28:47,980 --> 00:28:55,840 So not a static in 2018, we released a quick reference handbook, which was developed by Tim Cook and a group of Agabi, they've done a fantastic job. 272 00:28:55,840 --> 00:29:02,530 This is what they look like. So they've worked with groups Ariadne Labs, such as LaGuardia's Group that have done so much work in checklists. 273 00:29:02,530 --> 00:29:10,630 And this is the way the checklist and the cure now look, and it's based in with a lot of human factors to support it. 274 00:29:10,630 --> 00:29:19,180 Arguably, it's still not perfect, so I'll tell you why. It's why it's not perfect, but it it's quite it's quite busy looking after you, arguably. 275 00:29:19,180 --> 00:29:24,960 But many of these checklists, so for example, this one's tachycardia. 276 00:29:24,960 --> 00:29:31,270 It's usually the case that you'll have a patient with a protracted tachycardia and you've got time. 277 00:29:31,270 --> 00:29:37,900 So they're not losing their blood pressure, you're concerned, but you've got time, so you've got time to go through this with a colleague, right? 278 00:29:37,900 --> 00:29:44,320 Let's just think now what am I missing? These are not designed to remove your clinical autonomy. 279 00:29:44,320 --> 00:29:50,890 OK? They're designed to support you to release your frontal lobes, to think what's going on? 280 00:29:50,890 --> 00:29:57,970 Do I need someone else here? Just let me breathe for a second. Let's let's go through the basics and know that we haven't missed anything before. 281 00:29:57,970 --> 00:30:07,220 We have to start thinking about the really clever. That's just an example of circulatory bliss. 282 00:30:07,220 --> 00:30:10,910 And then we thought in the group when we got a little bit of funding from actually, 283 00:30:10,910 --> 00:30:15,350 well, it's all very well for us in secondary care what's happening in primary care? 284 00:30:15,350 --> 00:30:17,780 I had a colleague that came to me and said, you know, 285 00:30:17,780 --> 00:30:24,410 I'd really appreciate some support training teams in primary care because we're seeing a lot more emergencies. 286 00:30:24,410 --> 00:30:31,760 And so we thought, well, what does it look like out there and in and our very, you know, arguably back of a [INAUDIBLE] packet order? 287 00:30:31,760 --> 00:30:38,300 We found that 74 out of 76 jeeps had in the past year dealt with an emergency presentation. 288 00:30:38,300 --> 00:30:43,700 They all felt anecdotally that this had been going up and it interested me when I said, Watch your data, where's your baseline? 289 00:30:43,700 --> 00:30:46,130 They said, Well, we don't know. 290 00:30:46,130 --> 00:30:54,500 Because they don't have the same kind of records around admission that we do, they don't admit patients, so they never give you a diagnosis. 291 00:30:54,500 --> 00:31:02,840 You never know what's going on. They described a total of 301 emergencies, and the most common categories were accepted in acute asthma. 292 00:31:02,840 --> 00:31:08,990 So we thought, Well, let's start to design some checklists based in good human factors practise use a Delphi process of 293 00:31:08,990 --> 00:31:13,790 appropriate subject matter expertise and think about how we might support them in implementing them. 294 00:31:13,790 --> 00:31:17,690 Don't just go out there and do a little bit of simulation training and think, Right, take that's done. 295 00:31:17,690 --> 00:31:23,330 That'll sort them. No, that won't solve them. We need to leave them something to help them. 296 00:31:23,330 --> 00:31:30,170 So we've designed a few now. This is an example of the one that's the most common emergency acute coronary syndrome. 297 00:31:30,170 --> 00:31:39,170 So you can see someone is reading the list of statements down the left hand side where it's a start and then the boxes are colour coded, 298 00:31:39,170 --> 00:31:42,240 according to whether it relates to drug doses. 299 00:31:42,240 --> 00:31:53,360 So what what do you do if there's a critical change and then equipment and other instructions around particular circumstances? 300 00:31:53,360 --> 00:31:58,820 And then the purple boxes are usually about other relevant information that you may wish to turn to. 301 00:31:58,820 --> 00:32:03,110 So it's the left side that you go down, and that's what you need to train people. 302 00:32:03,110 --> 00:32:07,490 And that's what we did. And it was fascinating, actually. So we run a number of scenarios. 303 00:32:07,490 --> 00:32:12,140 Acute bronchiolitis was another one that they said they were all very, very frightened of. 304 00:32:12,140 --> 00:32:17,570 And of course, at this time of year, it's happening very commonly. And so we set up some simulation training, 305 00:32:17,570 --> 00:32:24,020 but we encourage them to use the checklist and we showed them how because many of them pick them up and started to read the orange box and said, 306 00:32:24,020 --> 00:32:27,980 Already, what's that all about? Oh, I see. Oh no, I need to start over here. 307 00:32:27,980 --> 00:32:36,230 And of course, there I was drawn to the colour. So arguably and I've spoken to colleagues with a specific interest in this area. 308 00:32:36,230 --> 00:32:39,170 The colour could be an issue. We need to think about that a bit more. 309 00:32:39,170 --> 00:32:45,860 But anyway, it's this is the start of the process and what we're hoping to do is develop a quick reference handbook along similar lines. 310 00:32:45,860 --> 00:32:51,500 And arguably we should have a quick reference handbook for in-theater emergencies. 311 00:32:51,500 --> 00:32:58,730 I'm sure we can all think of the sorts of things we would like people to run down, you know, if we had a maxillary artery rupture. 312 00:32:58,730 --> 00:33:07,850 Oh, right, what do we do? Bang, bang, bang, that kind of thing to support people in safe practise. 313 00:33:07,850 --> 00:33:16,310 So in summary. We definitely need to improve the way that we investigate incidents in health care. 314 00:33:16,310 --> 00:33:23,270 I look at some of the recommendations I did. I did a review of the serious incidents that happened in 15 16 in this trust, 315 00:33:23,270 --> 00:33:29,540 and the recommendations were very much along the lines of send them on that course. 316 00:33:29,540 --> 00:33:35,220 Give him a lecture. Have a meeting and tell everybody not to do that again. 317 00:33:35,220 --> 00:33:40,320 It's just not where we need to be. I think. 318 00:33:40,320 --> 00:33:48,060 There's evidence, at least a signal that implementation of external review can support that process, 319 00:33:48,060 --> 00:33:53,010 but we really need to train people around the region and nationally in how we do this. 320 00:33:53,010 --> 00:33:59,130 And Peter and others both spoken around the country on this subject. And so many people are saying, You know, what's this all about? 321 00:33:59,130 --> 00:34:03,810 Can you help us through this? Clearly a need that needs to be time for investing. 322 00:34:03,810 --> 00:34:10,260 How many of you investigate incidents? I mean, the do. I was just thinking about the last never event that I did. 323 00:34:10,260 --> 00:34:16,020 It took about 60 hours by the time I'd seen everybody written the interview transcripts. 324 00:34:16,020 --> 00:34:21,840 I remember the very first one I did I and I still I feel very bad about this, but there was just no way around it. 325 00:34:21,840 --> 00:34:27,840 And in fact, the person in question that I was hoping to see was a scrub nurse and we were both on call. 326 00:34:27,840 --> 00:34:34,240 And I was in the hospital at four o'clock in the morning and I thought, I think he's on over in the West Wing, I'm going to ring him. 327 00:34:34,240 --> 00:34:40,270 And I knew he was desperate to see me, and I knew that if we left it, I would be it would be another week. 328 00:34:40,270 --> 00:34:46,300 So I rang and I said, Look, I know this is a bit weird, but we're both in the hospital. Should we at least have a conversation? 329 00:34:46,300 --> 00:34:52,130 We're looking for you. Like, seriously, I'm sure we could do better than them. 330 00:34:52,130 --> 00:34:54,620 So. Checklist in. 331 00:34:54,620 --> 00:35:07,260 The evidence for the use, the the team effort, the belief in checklists that are properly designed and fit for purpose is very clear. 332 00:35:07,260 --> 00:35:13,410 But the way we're implementing them is still substandard, and we could do an awful lot better. 333 00:35:13,410 --> 00:35:21,150 And as an anaesthetist, I work in a lot of different theatre environments. You know, when I have a flexi session, I'll be sent pretty much anywhere. 334 00:35:21,150 --> 00:35:24,570 And it's fascinating to me to look at the culture. 335 00:35:24,570 --> 00:35:33,840 We do quite a lot of ethnography in the group, and I sometimes sit there with my ethnographers hat on thinking, OK, that was interesting. 336 00:35:33,840 --> 00:35:39,330 And we are actually using ethnography in some of the areas where these incidents has happened. 337 00:35:39,330 --> 00:35:45,990 To support teams in understanding what's going on in their culture and dermatology are a prime example of that. 338 00:35:45,990 --> 00:35:55,170 They are super keen, really determined that they're going to improve their their use of checklists and their safe practise. 339 00:35:55,170 --> 00:35:56,700 So thank you very much for your attention. 340 00:35:56,700 --> 00:36:02,100 I need to say thank you, particularly to the lady with the pink ring round, which she'll hate if she's in the room. 341 00:36:02,100 --> 00:36:12,430 But Janet is unfortunately leaving us super grateful for everything she's done to support Patient Safety Academy and, of course, to my colleagues. 342 00:36:12,430 --> 00:36:18,780 I've got that picture off the internet Astrofisica in space. 343 00:36:18,780 --> 00:36:24,630 They're fantastic. And to all of the people that have been involved in supporting the delivery of locks, Zipes, thank you. 344 00:36:24,630 --> 00:36:29,240 But do please keep working on them? We we really need to get this right. 345 00:36:29,240 --> 00:36:40,800 Right, right.