Quality and Safety in Anaesthesia

The agenda of quality improvement and patient safety is among the top priorities for individual anaesthetists, departments of anaesthesia and health care organizations. In recent years, since publication of the Institute of Medicine (IOM) report To Err is Human, there has been growing realization that a co-ordinated approach involving all layers of organizational management and clinical services is required to improve quality and patient safety.

Patient safety incidents remain a cause for concern in healthcare systems all over the world. According to IOM, as many as 98 000 deaths in the USA can be attributed to medical errors. In the UK, approximately 900 000 incidents and near misses are reported every year, of which around 2000 result in death. It has been estimated that additional hospital stay costs approximately £2 billion a year, and negligence claims amount to an extra £400 million a year.

This chapter addresses current concepts of quality and patient safety. In particular, the following topics will be covered.

The definition of quality

The culture of quality and safety

Can quality and safety be measured?

Tools for improving quality and patient safety.

QUALITY

Various attempts have been made to define quality in health care systems precisely. In the IOM’s 2001 report Crossing the Quality Chasm, six aims were proposed to define ‘what healthcare should be’. The six aims, i.e. safety, effectiveness, patient-centredness, timeliness, efficiency and equity, provide components of a working definition of quality in healthcare systems (Table 44.1). The six aims can be used as the attributes of a comprehensive quality care system, which can be continuously monitored and improved. These six aims are the cornerstones for designing and delivering a quality service from which both patients and clinicians are likely to benefit in terms of better patient care, less suffering and increased productivity and satisfaction.

TABLE 44.1

Aims of a High Quality Healthcare System

Any attempts to improve quality within an organization and a department, focussing on these attributes of high quality care, should consider whether there is organizational readiness to embrace the quality improvement programme. This will be determined by the existing culture within the organization and/or department. Establishing a quality culture within a department and making it more positive is the key to the success of any quality improvement interventions with regard to their implementation, staff compliance and sustainability.

CULTURE OF QUALITY AND SAFETY

Understanding Generation of Errors: Systems Approach

In health care systems, there is still a prevalence of a ‘judicial’ approach to errors. After an incident, people are generally quick to make judgements which often result in blaming the individual most obviously associated with the incident. This approach is a big barrier to understanding the nature of adverse events and how they can be prevented. In this regard, the healthcare industry has much to learn from other industries, such as aviation and nuclear power, which now have significant track records of a robust safety culture.

One central message from the IOM report has been that, in general, the cause of preventable deaths in healthcare systems is not incompetent or careless people, but bad systems. In order to reach this level of understanding, it is important to understand the aetiology of an error in complex organizations such as hospitals (Box 44.1). A safety incident should be seen in an organizational framework of latent failures – the conditions which produce error and violation – and active failures. This concept is captured in James Reason’s model of an organizational accident. It should be emphasized that some active failures (such as simple mistakes, lapse, fall, slip) have only a local context and can be explained by factors related to individual performance and/or the task at hand. However, it is now understood that major incidents evolve over time and involve many factors.

BOX 44.1 TAXONOMY OF ERROR

LATENT FAILURES are factors which exist within an organization or process and which increase the risk of another error causing an incident. They are separated in time and often in place from the occurrence of the incident. Reason described these as organizational influences, unsafe supervision and preconditions for unsafe acts.

Organizational influences may include aspects such as training budgets and curricula, and organizational safety culture.

Unsafe supervision might be reflected by a trainee anaesthetizing a complex case near the limits of their competence without adequate consultant supervision.

Preconditions for unsafe acts include lack of robust checking procedures, near-identical drug ampoules and inadequate rest breaks for staff.

Active errors are unsafe acts which cause (or could cause) an incident. They may be errors of commission (doing the wrong thing) or omission (not doing the right thing). Various categories of active error are often described.

Execution failures: the knowledge and the intent are appropriate, but for a variety of reasons the correct actions do not ensue. These are often referred to as slips (observable actions, related to attention) and lapses (internal events, related to memory failures). They may be failures of Recognition, Attention, Memory and Selection. These are exemplified by drugs errors in anaesthesia: every anaesthetist will be able to recall events where each of these failures has happened in their own practice.

Mistakes: the action proceeds as intended, but the wrong course has been chosen. These may be:

Rule-based: prior knowledge, intuition or a protocol is available for this situation (e.g. failed intubation) but is wrongly applied. This may be by omission, too late, or by applying the wrong rule.

Knowledge-based: an unfamiliar or novel situation requires the ‘calculation’ of a solution based on the (usually incomplete) evidence. These require thought and are particularly prone to confirmation bias – evidence which supports the current model is sought, and contrary evidence is ignored.

Violations: these are deliberate choices to deviate from agreed practice (formal standing operating procedures (SOPs), or informal custom and practice). Again, these can be subdivided:

Routine violations: corners are routinely cut. This may be at an individual or departmental level. ‘Normalization of deviance’ may occur, where unacceptable practice becomes accepted practice over time. The risk is that practice becomes further and further away from good practice gradually, such that it is not noticed or dealt with until too late.

Self-serving violations: breaking the rules for personal gratification.

Situational violations: breaking the rules because (correctly) the situation demands it. There will always be circumstances when rules and procedures do not fit. A safety-conscious organization seeks to learn from these incidents.

In the generation of an incident, organizational factors are the beginning of the sequence. These create latent failures which result from the negative consequences of management decisions, and organizational strategy and/or planning. The latent failures then permeate through departmental pathways to the workplace (e.g. the operating theatre complex). Here, they create conditions which allow violations and commission of errors. The errors generated in the workplace environment may be prevented by a front-end clinician (near-miss). However, a simple active failure on the part of the clinician at this stage allows the error to produce damaging outcomes. Figure 44.1 illustrates an example: how a medication error can result from a combination of latent failures, conditions contributing to error and violations, and active failure.

FIGURE 44.1 An example of the generation of a medication error.

In view of this knowledge, in order to facilitate quality and safety culture, it is important that, first, the healthcare organization must accept that in the vast majority of errors/accidents, ‘system’ failure has a major role to play. Second, the organization needs to be ‘open’ about it, and this openness and transparency must reflect in all their policies and procedures. Third, the organization’s response to these accidents must be ‘just’, and non-punitive for the individual involved. Finally, there must be mechanisms and forums so that ‘learning’ can occur at all levels within the organization, and so that systems are continuously improved.

Focus on Safety Behaviour and Non-Technical Skills

In clinical practice, some personal attributes of health care workers naturally render them more safe than others. These attributes are what one might see in a most highly respected member of a department.

Conscientiousness. Being sensible and meticulous, checking the information/drugs/equipment him/herself, ensuring that the job is done properly, and being thorough.

Honesty. Accepting limitations, giving correct and complete information, accepting own mistakes, compliance with procedures and protocols.

Humility. Thanking colleagues, juniors and nurses for their help and contribution, taking and seeking advice from other members of the team.

Self-awareness. Knowing limitations, knowing when tired, sleepy or pre-occupied

Confidence. Knowing capabilities and being confident about them, able to speak up if necessary.

There is now growing realization that these attributes along with non-technical skills are essential among staff to raise quality and safety in an organization. The General Medical Council in the UK makes it clear that doctors are expected to have these personal attributes. Detailed analyses of some of the high-profile incidents in anaesthesia have drawn attention towards non-technical skills. These non-technical skills (NTS) are defined as ‘The cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance. They are not new or mysterious skills but are essentially what the best practitioners do in order to achieve consistently high performance and what the rest of us do on a good day’.

The underlying premise is that:

the operating theatre is a complex environment with complicated tasks

many people come together to work in this environment

there is heightened potential for accidents and disasters in operating theatres, and

every human has limitations.

In view of these facts, and the recent knowledge about human behaviour under stressful conditions, it is important that health care organizations and workers have commitment to education and practice in non-technical skills. In particular, for the operating theatre environment, the following skills are important:

communication, sharing of information

team work

situational awareness

anticipation and preparedness

decision making.

Communication and Teamwork

Some of us are better communicators and better team workers than others. However, it is now well known that, if the skills are delineated, if awareness is raised about them and tools of learning are implemented by the organization, everyone can improve these skills beyond their previous level. The best possible scenario would be when all members of the team know each other, have mutual trust, are able to discuss problems and issues openly, learn from each other and work together for a common goal. Team leaders have special responsibility for ensuring that they have complete trust in the other members of their team. Listening to each other is extremely important to gain trust. In an ideal world, team members would respect and trust each other, know each others’ strengths and weaknesses, have a low threshold for discussion and learning, and would be able to manage and allocate tasks such that the job at hand is accomplished in the most efficient and safe manner with all members of the team deriving great satisfaction from a job well done. In practice, it is difficult to accomplish this ideal. Therefore, organizations must actively explore and implement tools and training programmes which allow employees to enhance their level of communication and team working.

Pre-list briefings are an important component of this process for the whole operating team. They are tools to foster good communication, planning and learning for the whole team.

Debriefings are a complement to the briefing process (Table 44.2). The concept is that the team reviews its performance each day – did it match the plans made at the start of the day? Good practice is reinforced and areas of improvement are discussed constructively. Information from debriefings should be shared with other team members and necessary actions should be completed and fed back to the team.

TABLE 44.2

Components of a Pre-List Briefing