audit conference

audit conference
audit conference

Wednesday, December 1, 2010

Safety culture

In recent years patient safety has become both a national and international interest. There is increased emphasis across the world on patient safety in policy reform, legislative changes and development of standards of care driven by quality improvement initiatives.

Safety culture was introduced as a specific concept of organisational culture in the aftermath of the Chernobyl nuclear reactor accident in 1986. It was found that the primary cause to this accident was by human error rather than technical failures. That human error was not due to shortcomings of the individual but rather a failure of the culture to realise that understandings of the inevitability of human error. 

What has to be accepted is that we live in an imperfect world: as human beings we all are prone to making mistakes and that no one system is perfect. However, when working in the delivery of healthcare we owe it to our patients and fellow colleagues to do the best we can. The key condition for safety in our high-hazard industry in healthcare is to support safe practices among ourselves: a culture that collaborates with open communication, teamwork, acknowledges mutual dependency and lastly the primacy of safety as a priority at all levels. To accept that mistakes and failures do occur and it gives us the opportunity to use the incident to reflect on what it reveals about the gaps and inadequacies in the healthcare system.  

In reality health care providers are usually more interested in the accountability of individuals, assigning ‘blame’ for mistakes persons working on the ‘front line’. According to the research describes how healthcare has two main obstacles to improving healthcare safety: firstly a belief in ‘training perfectly’, that after long and demanding training healthcare professionals expect - are expected - to get it right! And the second point that there is a tendency to stigmatize and sanction fallibility (error is equated to incompetence) these two traditional influences have made it difficult for healthcare providers to admit their mistakes and learn from the mistakes that have happened.  

 Another aspect is that healthcare providers often encounter errors during their clinical practice for example the infection rate on CBI (catheter – related blood stream infections) they may regard the occurrence of infection as an acceptable level whereas proper hand washing could eliminate such infections. Working in a hierarchically organisation of accountability and responsibility does not lend its self to reporting problems. A problem could be taken as a personal attack rather than a constructive opinion that may help the organisation by improving the present system. 

It is important to access the safety culture of the organisation in order to develop patient safety. The WHO launched a series of activities in highlighting topics into patient safety in order to identify poor health practices. The new safe Surgery Saves Lives established a “WHO surgical checklist” as a working tool for surgical teams worldwide to ensure patient safety. This one page document which contains three main components: “Check in” (before induction of anaesthetic, “Time Out” (before skin incision) and “Sign Out” (before patient leaves theatre). The document is to reinforce the patient as central focus of care, improve team communication and lastly promotes positive patient safety culture. 

There are many different interpretations of the “time out” protocol. Most theatres tend to follow their own protocols. The recognised practice of “time out” is immediately prior to commencement of surgery. All surgical team members stop what they are doing to participate in the time out. The surgeon, anaesthetist and the scrub nurse should undertake a “time out” to verbally confirm the intended site, operation, side and identity of the patient checking this information against the patient’s identification bracelet, the operating list and the consent form/patient health records. The surgeon, anaesthetic and nurse can verbalise any patient-specific concerns I.e. anticipated blood loss, equipment issues or any concerns. Research confirms that wrong site surgery is rare, but it is tragic for the patient, surgeon and all other healthcare providers. 

The theatre is regarded as one of the more complex working healthcare environments. It consists of a very high level of technological equipment and a multiple disiplinary approach of personal, ranging from surgeons, anaesthetists, medical students, nurses and nursing students and theatre technicians. There is an associated high stress levels in performing in a high-risk situations and under a time restraint. The incidence of medical error in Ireland according to the Institute of medicine report is 500 – 550 of hospital deaths per year.

Surgical complications are common and often preventable. Some of the reasons believed to be the contributing causes to surgical errors are: poor preoperative planning, failure of the surgeon to exercise due care, lack of communication between the patient and the physician, misreading of patient’s results I.e. patient’s x-rays. Another preventable incident is where the patient’s specimen goes “missing”.  Where a patient goes through a surgical procedure in order to obtain a sample of the tumour/growth, in order to get a diagnosis and specimen has not gone to the Lab. In some hospitals the responsibility has been given to the scrub nurse to look after the specimen. This practice could be perceived unfairly that the medical team can not be trusted to ensure that such an important specimen would reach the lab.   

An analogy that tends to be used to compare safety in the operating theatre is the aviation cockpit of an aircraft. The responsibility of life and death situations that is left in the hands of the surgeon or be it the pilot is the common link. “Team work in the operating theatre lacks the formalisation of aviation cockpit crew” Grote et al (2004). That the Tenerife air crash accident of 1977 highlighted the undue stress that was put on the pilot compare to the stresses of a surgeon going to perform an operation. The one aspect that maybe considered is that the pilot must do their own checklist and are not reliant on their co-workers to take away his/her responsibilities. Health and safety is very much involved in the whole aspect of the aviation industry. For example the amount of flying time that is restricted to avoid potential accidents due to fatigue. Surgeons on the other hand have a restricted time in public hospitals but what about their private patient time? Another issue is the classic illegible handwriting situation that has a huge scope for misinterpretation leading to confusion and health risks. Where are the mandatory stipulations that any clinical document must be printed in legible handwriting?  

Both pilots and surgeons are very much dependant on “team work” and yet there is a problem with surgeons lack of “buy in” to the concept of “time out”. Like everything new it takes time to adjust to new ideas. And yet this “Time out” process is very much led by the nursing profession. It seems that initially it was perceived as a repetition of documentation. It has to be acknowledged that it was the nurses who took it on board and streamlined it to what it is now.  Implementing a patient safety solution needs a standard National policy and a checklist to encourage compliance and to avoid the ciaos of variance that leads to confusion. There should be a shared responsibility to ensure correct site surgery amongst nurses and medial staff. By reviewing and auditing the process together as a team it can reduce the barriers and encourage education and communication. Lastly this will make not only the patient’s safer but will reduce costs of litigation and pain.       

Monday, November 29, 2010

A brief description of the role of the HSA in Ireland

The role of the health and Safety Authority in Ireland.
The Health and Safety Authority (HSA) has overall responsibility for the administration and enforcement of health and safety at work in Ireland. They scrutinise compliance with legislation at the workplace and can take enforcement action that can lead to prosecutions. A prosecution is used as a last resort. Most of the HSA activates are centred on: inspections through to policy formation, technical services, information and guidance. Only when a preventive approach is disregarded, they will take legal action to protect workers and to enforce safety in the workplace.
The HSA 201 – 2012 vision, is to develop employers and their employees to a culture that will commit to health and safety in their workplace. The recent addition to the HSA role is the sustainable management of chemicals in the workforce. Pharmaceutical companies have developed a thriving business here in Ireland and have developed a lot of employment in the Irish markets.  
The HSA also promotes education, training, research and publications in the field of health and safety. Some of the areas they are involved are;
Agriculture and forestry
General application regulations
Workplace transport safety
Machinery and workplace equipment 
Mines and Quarries
Safe system of workplace
The HSA has an obligation to the public sector/ tax payer to give value for money. They have a commitment to their customers to provide information and advice to the implementation of regulations to the less proactive clients on health and safety in the workplace. They also have the values of quality and to strive for continuous improvement with the organization. The HSA have a commitment to venerable employees, to act with speed and agility to rectify wrong doings that have been done. The goals of the HSA are to provide framework guidance for employers to follow.  To be committed to a safe work environment.  The HSA encourages organization s to have the capacity to be productive in their line of business, provided they do it in a health and safety manner. 
Those who choose to disregard advice and recommendations from the HSA need support from the minister of Enterprise, Trade & Employment in the initiation and development of appropriate legislation and policies in order to give the organization credibility.The HSA have identified certain areas where key cost cutting themes has occurred. The areas relate to employer/employee categories, for example pregnant women where special requirements are needed at different stages of their pregnancy. Risk- rated resource allocation, Partnership – employer/employee relationships.
 “Working to create a national Culture of Excellence in workplace safety, Health and Welfare for Ireland” (HSA 2009). It was a major program of regulatory reform coming from the introduction of safety, health and welfare at work (general applications) Regulations 2007. These regulations replace, simplify and update the 25 existing set of regulations and orders and apply to all places of work. The authorities implemented a proactive inspection program. 13, 631 inspections were carried out in 2007. These inspections focused on: Risk assessments, preparing and implementing safety statements and the responsibility of managers and directors.    
The report indicated 70% compliance to having a Safety statement in their place of work. The two areas where non compliance to safety regulations occurred were the construction and agriculture industries. The HSA took legal action where it was found necessary to enforce compliance. In 2007, 31 prosecutions were made and finned 784,372.59 Euros. The figures also showed from the HSA records that 67 deaths occurred compared to 51 deaths in 2006. The two areas that had high fatalities were fishery where 12 deaths happened and in the construction industry where 18 deaths in one year.  
The ‘Programme for work 2010’ anticipating it to be published to the general public at the end of October. described the four main divisions. Where three are looks outwards while one looks internally at human resources, information technology and legislation. These divisions are;
  • Chemical Policy and Service division for 2010.  
  • Prevention  
  • Compliance 
  • Corporate Services POW 2010

When focusing on the construction industry. One can ask the question: How do increasing risks occur in a changing industry. How industry has moved from a large scale to small sites. Here is the resulting in a shift in the types of accidents. The Construction Safety Partnership (CSP) is now focusing on smaller contractors.  Where the CSP can provide meaningful H&S educational programs to contractors. They can also increase awareness of the standards among smaller contractors. The HSA is organising an E-learning program for employers and employees in the understandings of a simple ‘Risk Assessment’ package. In order for the HSA to be effective it needs the legal support from the government. The legal framework, Safety, Health & welfare at Work Act 2005 is applicable to all work areas in Ireland. Where Parliamentary Acts and regulations are there to put in place where it is necessary to protect and prevent incidents happening. 
The area I needed to know was how workplace inspections operated. Apart from what has been earlier being discussed about the many roles of the HSA. Workplace inspections are a very important role where the inspector calls to the place of business to follow-up from a line of enquiry either by the public or by their own process of enquiry. The inspectors’ role is not always to punish but to provide information and advice as a preventative measure. The HSA do have the power to prosecute but this can be used as the ‘last resort’. The main areas that are given most attention is the high risk professions:
Construction industries
Mines and Quarries

The main areas for concern I feel are the safety at heights and vehicles. In the health section would be the manual handling and level of noise that could have long term affects for employees. The role of the inspector is the role of reactive to fatalities at work. Where there could be criminal or civil implications associated with the fatality. Any serious accidents and dangerous occurrence are thoroughly investigated by the HSA as well as the Garda. In order for employees to gain confidence in the HSA they need to publicise their role and also to conduct regular site inspections on a regular basis.   

When the inspector calls to the organization or business they are ensuring that the safety statement is on display. The inspector role is to find out, the extent to which employers, directors and senior managers are aware of their safety and health responsibilities.  Inspectors will negotiate with the person in charge (the most senior person in charge) in the workplace at the time of the inspection.  The inspectors makes enquires about the extent of the managements knowledge on their responsibilities and how they are implementing them i.e. how are they ensuring they will not be subject to a Section 80 offence. They will also meet the Safety and Health Manager/Adviser and the Safety Representative 

Following the formal introductions the inspection will initially review relevant safety and health documentation including the safety statement and/or the safety and health plan as appropriate. A workplace inspection will follow using a sampling approach, covering the key risks aspects of the business as identified in the safety and health documentation for example; Safety Statement, sign off sheet, Assessment, Risk assessments and records of training, accidents, certifications. 

 The inspector needs to establish the suitability of the control measures in place for these risks. A close out meeting is then held with the most senior person in charge on the day, preferably the Managing Director /CEO, Company Director or other responsible senior manager in order to give a verbal or written report of the inspection. They may also need to explain and serve Enforcement Notices on the employer. At this meeting the inspector also reviews with the senior manager his/her level of awareness of legal responsibilities under the 2005 Act and the level of their implementation of these responsibilities.  

Another relevant question, I feel needs to be answered: Are hospitals visited by the health and safety authority?
In the last couple of years there have been demands on hospitals and in the healthcare organizations to show their level of quality care. These demands come from a variety of areas including patients, colleagues, tax payers and public representatives. Healthcare is progressing with new technology and with new patient demands. The patient has changed from being subservient in nature to now being more informed with high expectations. Presently, an accreditation has promoted and been endorsed in many of the acute services. By the setting of national standards, it makes healthcare organizations accountable and responsible for their clinical governance. The drive for best practice even in these trouble times is very much set as a priority for the healthcare organizations. Once a hospital is accredited it does influence the payment system to the hospital I.e. Health insurance companies, VHI, BUPA VIVAS. 

In the Health System for you (2001) that describes a framework for change. It focuses on human resources and in particular the staff, by using word like ‘securing’, ‘protecting’, ‘developing’. The Safety, Health and Welfare at Work Act 2005 emphasises the importance of managing safety and health in all workplaces. Auditing described by the Guidance Document for the Healthcare Sector is a process whereby a healthcare organization can independently evaluate (audited either internally or externally) its safety and health management system.  By achieving the objectives of the audit tool through the development and implementation of a safety and health management system it will enhance a greater level of commitment of the workforce.  I would like to hear from your experiences in this area,,,,