Resources Module 5: Learning From Error

Patient story

In 2001, an apprentice mechanic, Wayne Jowet, 18 years of age, was recovering from Leukaemia. The teenager, from Keyworth, Nottinghamshire, was in remission and was being treated as an outpatient at Nottingham's Queen's Medical Centre in UK in January 2001. A specialist registrar was asked by the senior house doctor (SHO) to supervise the treatment of Mr Jowett. The specialist registrar, who had joined the hospital just two days ago, failed to note what was written on the patient's haematology charts and handed the junior doctor (SHO) two drugs instead of one and also failed to check the route of administration and the syringe, which would have stated that the second drug was Vincristine and would have told him that the drug should have been injected into a vein. So, both drugs were administered into the spine by the SHO after approval from the specialist registrar. The patient died four weeks after the error at the Queen's Medical Centre in Nottingham in February 2001. The specialist registrar was charged with “manslaughter” by the public prosecutor and was sentenced for eighteen months in prison while the SHO was disciplined. (Dyer, 2003) (Britten, 2001)

Learning from error

Runciman defined “Error” as “When someone is trying to do the right thing, but actually does the wrong thing”. Reason, defined it as “planned sequences of mental or physical activities that fail to achieve their intended outcomes, when these failures cannot be attributed to the intervention of some chance agency”. A “Violation” is defined as, “ A deliberate deviation from an accepted protocol or standard of care”

The patterns of errors that occur in healthcare settings are no different from the situations that exist in other industries. What is different about health care is that there remains an element of a culture of infallibility that denies the prevalence of error.

Errors occur because of one of two main types of failures: actions do not go as intended (skill based slips and lapses) and the intended action is the wrong one (mistakes). Situations associated with increased risk of error include: inexperience, time pressures, contingency teams, inadequate checking, poor procedures and inadequate information. Individual factors that predispose health­care providers to errors include: limited memory capacity, fatigue, stress, hunger, illness, communication errors and hazardous attitudes.

There are two ways to learn from error:
1) Incident reporting: Incident reporting and monitoring involve collecting and analysing information about an adverse event that could have harmed or did harm a patient in a clinical setting.Strategies for incident reporting include:
• Anonymous reporting (use of electronic anonymous systems)
• Timely feedback by leadership on actions to prevent same errors
• Public acknowledgment of successes of organization’s reporting in lowering adverse events and errors
• Anonymous reporting of near misses

Read more using WHO handout, Learning from error (WHO, 2012a)

2) Root cause analysis: It is a structured approach to incident analysis. It was first established by the National Center for Patient Safety of the US Department of Veterans Affairs.The RCA model focuses on prevention, not blame or punishment. The focus of this type of analysis is on system­ level vulnerabilities as opposed to individual performance. The model examines multiple factors, such as communication, training, fatigue, scheduling of tasks/activities and personnel, environment, equipment, rules, RCA focuses on the system, not the individual worker, and assumes that the adverse event that harmed a patient was caused by a system failure. A severity assessment code is used to help triage reported incidents to ensure that those indicating the most serious risks are dealt with first.

The defining characteristics of root cause analysis include:
• review by an inter­professional team knowledgeable about the processes involved
• analysis of systems and processes rather than individual performance;
• deep analysis using “what” and “why” probes until all aspects of the process are reviewed and contributing factors are considered;
• identification of potential changes that could be made in systems or processes to improve performance and reduce the likelihood of similar adverse events or close

Read more using WHO handout, Root cause analysis (WHO, 2012b)

Resources for optional reading include:

Chapter 35, Error Reporting and Disclosure from the book “Patient Safety and Quality, An Evidence­ based Handbook for nurses” (Hughes, 2008)

Using aggregate root cause analysis to improve patient safety (Tutorial, 2003)

Improving Root Cause Analysis and Actions to Prevent Harm, National Patient Safety Foundation (NPSF, 2015)

References:

Britten (2001) Doctor warned over drug death. The Telegraph [Online][Accessed on 29 April 2021][Available at [http://www.telegraph.co.uk/news/uknews/1337592/Doctor-warned-over-drug-death.html]
Dyer (2003) Doctor sentenced for manslaughter of leukaemia patient. BMJ 2003;327:697 [Online][Accessed on 29 April 2021][Available at http://www.bmj.com/content/327/7417/697.2]
Hughes (2008): Chapter 35, Error reporting and disclosure from Patient Safety and Quality: An Evidence-Based Handbook for Nurses.Agency for Healthcare Research and Quality (US) [Online][Accessed on 29 April 2021][Available at  http://www.ncbi.nlm.nih.gov/books/NBK2652/]
Tutorial (2003). Using aggregate root cause analysis to improve patient safety [Online][Accessed on 29 April 2021][https://www.researchgate.net/publication/10583945_Using_Aggregate_Root_Cause_Analysis_to_Improve_Patient_Safety]
World Health Organization (WHO) (2012a). Learning from error [Online][Accessed on 29 April 2021][Available at http://www.who.int/patientsafety/education/curriculum/course5_handout.pdf]
World Health Organization (WHO) (2012b). Root cause analysis [Online][Accessed on 29 April 2021][Available at http://www.who.int/patientsafety/education/curriculum/course5a_handout.pdf]

Last modified: Tuesday, 8 June 2021, 6:48 AM