SNOW DAY. Lessons on Improving Patient Safety.

This was the photo that made page two of the Dundee Evening Telegraph tonight thanks to our resident journalist Katie. A short clip about the 'avalanche' of snow which fell of the roof of the house and bashed in the roof of the car. Luckily I was able to push out the roof from the inside back into shape but a good story none-the-less! Shame about the neighbour's car whose back windscreen wiper snapped right off though.

I'm into the second week of the Improving Prescribing Theme SSC at the moment and much of the emphasis on the first week has been patient safety and reporting of errors. This is an important topic because a study in 2001 found that 12% of UK hospital admissions involve some form of adverse event. People never make mistakes intentionally but they are a common occurrence, even in the top medical institutions. Much of the time the mistakes come down to faults in communication and it's important to emphasise that it is nearly always the system which is at fault rather than individual blame. In the past there was much more of a 'blame and shame' culture of reporting errors however this has now changed with an increasing shift towards open reporting of incidents. One way to think about the way errors to occur is to imagine the 'Swiss-Cheese Model' where an adverse event occurs when a series of holes in the system are breached.

Ways of investigating an incident can include a 'Root-Cause Analysis' which is often started using a simple 'fish-bone' diagram. The factors to consider in how an incident occurred include:

1. Patient Characteristics
2. Task Factors
3. Individual Staff
4. Institutional Context
5. Work Environment
6. Organisation and Management
7. Team Factors

After considering each of these areas in turn, it is then possible to get an idea of the bigger picture of what led to an event occurring. We've been set a task in a small group to investigate an incident on one of the wards in Ninewells where an error was made an a patient was prescribed an overdose of an anticoagulant. During this week we'll meet as a group to discuss each of the factors in turn and then generate a report. Hopefully the plan will then be that once we have made our report, we'll be in a position to make a recommendation on how practice can be changed to stop this kind of incident from happening again. It's been an interesting course so far and will hopefully continue this way, unless the snow interferes too much! I'd advise anyone interested in this to look at the IHI Open School Website for more information.