Incident At Queen Medical Centre

Introduction

In this essay, I will describe an adverse incident of Mr Wayne Jowett which has happened at Queen’s Medical Centre hospital in Nottingham. An adverse incident can be any event that has the potential to cause the deviation of a system or process of performing a task from the optimum (Walshe, 2000). Reporting an adverse incident is important because the existing managers can learn from their mistakes which will help them in improving the quality of care in future (Reason, 2000).

Following the report of the incident, I will then use public event data to provide the root cause analysis of the main contributing factors, that led to the adverse incident, using a fishbone diagram and investigate four root causes, chosen from the diagram, and each root causes will be analysed by using the swiss cheese model to discuss about what were the barriers , what were the vulnerabilities and supported with solution. I will be analysing this with an in depth research using the detailed scenario in appendix 2.

Background of the problem

Patient safety is the reduction and mitigation of unsafe acts within the health-care system, as well as using best practices to lead to the optimal patient outcome. A basic proposition that serves as the foundation for a health system of belief (World Health Organisation, 2017). A lot of studies have been done showing that numerous patients are harmed during healthcare, resulting to either permanent injury or death. It is estimated that, around 1 in 10 patients are hospitalised due to undergo harm with at least 50% that could have been avoidable. It is also estimated that, around 421 million admission in hospital for treatment take place in the world yearly, and nearly 42.7 million adverse events happened with the patients through the process of hospitalisation. In some countries, the cost of poor care is between US$ 6million and US$ 29 billion annually. Although, this is different in other countries. For example, in the United Kingdom, it was estimated that, the cost of preventable adverse events is about £2.5billion per annual (Frontier economics, 2014).

Meanwhile, in the United States of America (USA), the policy makers concentrated in saving estimating about US$ 28 billion between 2010-2015 by improving exact patient safety guidelines (WHO, 2017). In 2004, the National Health Service Litigation Authority (NHSLA), estimated that, the cost of clinical negligence claim was £7.78 billion (Dingwall, 1994). Therefore, it is important to have a strong business case of patient safety because improving safety lead to improved quality, that will reduce cost, improve outcome and use resources to maximise efficiency while bad healthcare creates cost and worst resource utilisation (David Newbold, 2018).

Rational of the problem

Wayne Jowett,18 an apprentice heavy good vehicle mechanic suffered from cancer and had been receiving leukaemia treatment at the Queen’s medical centre in Nottingham (Support the Guardian, 2001). According to Toft, (2001), after a successful treatment of leukaemia, on Thursday 4th of January 2001, at about 17.00 hrs, a day ward E17 at the QMC Nottingham was prepared for an intrathecal (spinal) administration of chemotherapy as part of the way he has been taking treatment, however, this time it was unlucky.

Fishbone diagram graphically link the problem with potential root causes (Ishikawa, 1990). Each cause provides an avenue for incremental reduction in the likelihood of the adverse result happening. Based on the enquiry made from Mr Jowett death, a root cause analysis was created to identify what lead to Jowett death. The outcome results to the failure of identifying the wrong drug and the rout of administration (Toft, 2001). In the process of enquiry, numerous risk factors unfold were used to create a fishbone diagram in appendix 1. According to the Swiss cheese model by James Reasons, it helps to increase awareness of the condition which put staff and management at risk to error (Donaldson, 2002). Root cause analysis is the process of identifying the underlying causes of problem wherein healthcare providers take a step back and gain knowledge from adverse events, near-misses in the operating room and all the areas of healthcare to improve the safety of the patient (Dattilo and Constantino, 2006).

Communication factor

The procedure all the staff used to carry out Mr Jowett treatment was negligent. The communication between members while most of the nurse ask a question from the senior house doctor who was supposed to take up the treatment before the doctor left the hospital and assign the new doctor to carry on with the treatment, answers to the nurse questions were not always in detailed. The doctor took up the procedure misunderstood the drug Vincristine to Methotrexate, and the doctor failed to note what was written on Mr Jowett haematology chart and failed to complete the appropriate check for which of the drug should have been administered because Vincristine and Methotrexate are two different drugs.

In healthcare settings, the main cause of adverse incidents is based on the lack of good communication skills. Dunn et al., (2007) stated that, a report by joint commission shown 65% report on adverse events are caused due to the barriers of effective communication. Similarly view by Gawande that, ineffective communication amongst the workforce was responsible for 43% of adverse events (Gawande, et al., 2003). Mr Jowett was not openly involved with the administration process. According to Kanerva, et al., (2015), staff-patient communication skills are the most challenging factors of patient safety problem. Mr Jowett the first victim also failed on his own part to notify the staff members that he would be able to attend his morning appointment after previously missing series of appointments and that he will be attending later.

Therefore, the senior house doctor who oversees Mr Jowett treatment left the hospital before Jowett arrival. Furthermore, the junior doctor who brought the second drug read the guidelines from the label but failed to read the route of administration. The failure of communication between physicians and nurses cause 91% of medical faults (Najafpour, et al., 2016). The hospital failed to provide the new doctor with the required documentation about the administration code and drug custody of practice of QMC (Toft, 2001). Organisational guidelines and procedures determined what information by who and when should be transferred are very paramount (Rabol et al., 2011).

Effective communication is one of the major strategies that is related to patient safety in the hospital. In Mr Jowett case, the medical team members should have involved with him all through the treatment process including the first time the treatment commerce, that is informing him the dosage of drug for the next appointment and this would have helped him to challenge the doctor to stop the administration of the second drug because the doctor is ment to administer one for him a day. The need of putting patient in the centre of care is very important, as it helps with the ability to reduce adverse consequence related to prescribing (Britten et al., 2000).

Health organisation should provide communication skills training programmes for staffs (Berkhof et al., 2011). Policy makers can play an important role in prioritising this to improve patient safety so that that medical professionals involved in the procedure must read information on drugs label to make sure that they have a good understanding of the route of administrating drug to patient. In healthcare setting, information should be in the form of verbal and written to understand any treatment before it begins.

Communication between healthcare professionals influences job satisfaction, quality of working relationship and profound impacts on patient safety (Quality and patient safety, 2018). To avoid error in healthcare settings, the managers should always implement shared mental model to improve team performance if they have a shared understanding of the task that is to be performed, it will improve the communication skills. This model has for component; Situation, Background, Assessment and Recommendation (SBAR) (Beckett and Kipnis 2009).

Analyses:

In order to achieve good quality safety merit for patient, health professionals need communication skills in adequate form to approach improvement from the view of correcting blemish system and using standard communication tools to reduce errors that will cause patient harm (Leonard et al., 2004).

Safety culture is an essential aspect in facilitating and supporting effective communication across the organisations, where the organisational work ensures personnel confidence and enhances patient safety (Nieva, VF and Sorra, 2003). Hence, the managers, applying safety culture, could support the staff about the organisational belief and value and may enable staff to have open channels of communication assertiveness, transparency and trust, and strong leadership that will promise effective flow of high quality knowledge and information.

Education and Training

Lack of training was one of the causes of Mr Jowett death. The doctors involved in the treatment suffered from newcomer syndrome, they were not provided with any training in the administration of the highly toxic drug by the hospital. A study done by Dizon et al., (2014) suggested that, lack of knowledge and skills among healthcare professionals hinder improved quality in healthcare.

The actual cause also results from inadequate time because when the junior doctor brought the second drug in, the senior doctor told him to open it very fast and hand it to him (Toft, 2001). The assessment to understand that, the staff know the right treatment procedure was insufficient. The two doctors, who are involved on the treatment procedure of injecting the intravenous chemotherapy, were not trained by the hospital because the senior medical team in the hospital believe in their reliability (Toft, 2001).

Induction training is important for new staff because it provides a comprehensive snap chart of the organisation and educate them about the culture, values and principles of the organisations. In QMC, it is important for management to introduce a compulsory staff induction for the new employees, because an effective and timely induction training results in influencing the employee perception about the organisation. Lingard, et al., (2004) stated that, effective teamwork training and use of safety tools like checklist help to eliminate the main causes of procedural error, inefficiency, patient inconvenience and so on. According to Huges et al (2016), the significance of training for healthcare professional reduce medical error. Guidelines are more general nature and are systematically developed statement that help professionals and patient in decision making about the right healthcare for condition (Bullas and Ariotti 2002).

Providing training and education to healthcare workers enable them to identify the ability to prevent harm. According to Fateminejhad and Kolahjoei (2013), providing education and training serves to update staffs knowledge and professional skills that also promote competency and empowerment for better understanding of their task. This should be a strategy process where the manager would adopt in healthcare settings. Baker, et al (2005) emphasised on team training as a hallmark of high reliability successful interventions in medical demines. This is in line with Gelhaus (2018) who highlighted that, providing training improves both patient and clinical process outcomes and significantly helped to reduce mortality and morbidity rate in medical procedures.

From the beginning of Mr Jowett treatment, a lots of teamwork problem arises; for example, it started from the pharmacy room where the pharmacist prescribed both drugs same day which was ment to be given in different day. (Toft, 2001). St Pierrer, et al (2008) stated that. failures in teamwork cause directly substantial contribution to adverse incident of medical error. According to St Pierrer, et. al. (2008), lack of teamwork and communication has resulted in 61% of sentinel events. The Junior doctor who was assisting the senior house doctor in the administration of drug procedure was not self confidence to the question the senior doctor asks him when he brought the second drug in to the room (Toft, 2001).

Healthcare organisations first principle duty is to provide an effective teamworking system. This can be attained by introducing a safety culture through the policymakers, and an emphasis on the engagement of healthcare leaders (Millar R, et al., 2013). This would allow the organisation to operate under a safety climate. According to Nieva and Sorra (2003), safety culture of an organisation are built by shared perceptions of the importance of safety by communication founded on mutual trust and by confidence in the efficacy of preventive measures.

This mean that, organisation should focuses on the care that is delivered, the service providers should be comfortable talking about errors and near-mises and actual harm without fear. Teamstepps training should be another training that would be introduce by the organisation; although this has been implemented into healthcare training program because it positively affects the multiteam system contexts for supporting sustainment of behavioural changes, it is possible toachieve through training (Weaver et al., 2014).

However, In Mr Jowett case, these safety measures were in place to avoid the incident but was not utilised by the staff. This is the reason the frontline managers should introduce safety 2 theory that look at the complexity of healthcare system which need to be investigated not to continue to happen again rather than safety 1 that focuses on single point of failure.

Patient safety climate has positively impacted the improvement of patient safety and the organisations safety performance (Nieva and Sorra., 2003). For example, organisation operates under safety climate, staffs interact and understand what they need to do to be supported, reinforced and rewarded to maintain patient safety.

Weaver et al., (2014) stated that, organisations, who apply the Teamstepps training methods, have seen how the techniques have enhanced the performance of staff team and communication skills to health and personnel of patient safety, and emphasis each staff as an important member of the team. Safety 1 and 2 view the solution are design to avoid harm and improve patient safety (Hollnagel Wears and Braithwaite, 2015). Policymakers incorporating safety 2 theory would help organisation to handle salient barriers (Lapinte and Rivard 2005).

Mr Jowett death also results from the organisational structure. The last treatment of Mr Jowett with the first senior doctor was that Mr Jowett request to deferred the procedure of his surgery which the doctor agreed to his request and note the information on Mr Jowett clinical note but failed to document it in the software system for other staffs to easily access (Toft, 2001). Walshe (2002) stated that, the problem of organisational structure is lack of basic management systems.

Similarly view by Vincent et al., (1998), it provides a condition for inadequate system of communication act to occur and influence the employee performance that cause harm and affect patient outcome. The organisation failed to use different labelling containers for the two syringes and stored in a different prohibited area.

Healthcare organisations must create an effective structures and environment for efforts. To achieve this, organisation should invest in risk management systems and implementation of formal safety program (Brunsson Jacobsson et al., 2000). This would enable the institution to have priority of safety. According to Zohar, (2000), priority of safety build a relationship with safety performance. QMC organisation should provide information technology training for staff to continue improving and reviewing the systems before engaging in surgery as it helps to support patient record as well as staffs in decision making (Nemeth and Cook, 2007).

Organisational priority for patient safety has helped to improve organisation structure. Hendrich, et al., (2006) stated that, where organisation initiated crucial programs, train staffs and implement new safe practices, staff will maintain a safety culture. According to Leape et al., (2009), to accomplish a safety culture, organisations must provide a strategic guidance for attaining safe healthcare. Hence, organisation implementing safety culture and five main transforming concepts would encourage the staff to promote a high reliability organisation.

Vincristine safety issue has been debated since 1989 (Eric T, 2016). Medical expert has conducted assessment on high rate of medical error and what they found uncover the risk of administering Vincristine intrathecally rather than intravenously. For example, organisation institute may have failed to comply with risk reduction strategy related with labelling bags of Vincristine with important warning and documenting patient information in the system.

Since 2001, the joint commission endorsed the implementation that hospital must check any prescribed intrathecal medication that have been administered before providing Vincristine (The Joint Commission, 2005). After this, it found out that, the healthcare adopts less of this recommendation. The National Comprehensive Cancer Network (2016) stated that, raising awareness to hospitals would help the organisation to train the staff to adopt the strategies that will improve the quality of services.

The above evidence justified that staff in some healthcare institutions use different manners to attain effective communication. A study conducted by Milch et. al. (2006), in terms of the seriousness of error in emergency department highlighted that out of 92457 errors, 1.4% was submitted by the physicians. Hence, the earliest implementation of a reporting system by the managers for reviewing evaluation and supporting staffs to use reporting system for incident is essential and would prevent hospital’s adverse events which cause harm to patient. According to Von Dossow and Zwissler, (2016), the application of SBAR by healthcare providers and organisation has shown some positive effect. However, in some healthcare institutions, this briefing model has not been effectual. For example, over 200 million surgeries carried out worldwide annually, adverse event rate for surgical condition increased despite of the use of SBAR checklist (Wang et al., 2014). This result from communication failure between the healthcare providers which led to inaccurate patient plans for treatments.

The implementation of SBAR should be a structured method of communication that will ensure that clinical information is passed on effectively and efficiently through evaluation system. The evidence to measures the effectiveness of the perceptions of workforce on health and safety issue in healthcare organisation is limited (Abdullah et al., 2014). Noted by Institute for Work and Health (2007), most healthcare organisation leader’s usefulness of safety climate is limited like the staff behaviour. This could place limitation on the support of the organisation leaders who may provide for important differences inside the organisation.

Safety 1 and safety 2 theories have contributed to the death of Mr Jowett, comparing both the theories are very essential. For example, although safety 1 reduces harm to patient but safety 1 assumes that, things go wrong because of malfunctions within the organisation (Hollnagel, Wears and Braithwaite., 2015). Although, according to Ball and Frerk (2015), lay greater stress on how healthcare systems challenges could result from uncertainty, complexity and risk.

After the death of Mr Jowett, a root cause analyse was generated, this identified the areas need to be improved in the hospital whish most of it has been discussed above. Safety 2 assumes that, incident can occur despite the circumstance result (Hollnagel, Wear and Braithwaite, 2015). According to World Health Organisation (WHO), in 2018, 50% to 70.2% of adverse event harm could be prevented by a lot of systematic procedures to patient safety. Although, in healthcare settings with high demand, the prevention of errors may be expected. For that reason, organisation policy makers should emphasis on the implementation of safety 2 theory to improve the safety of patient in healthcare environments.

Recommendations

The analyses above have clearly shown that, patient safety is a crucial concern in the healthcare institutions. Among the recommendations shown above for policy makers on ways patients’ safety can be improved appear that, there is no single approach that can prevent harm but there are different factors that the organisational leaders would do that for handling and resolving harm. For example, seeking high reliability to embrace a just culture in all would lead to safety climate as identify above, and this includes a systematic approach to analyse near-misses and harm events.

Training and educating staff and policymakers are bringing difference of current tools such as SBAR and Teamstepps that could help the staff to make the best use of their knowledge on teamwork and communication skills. For future, the principle of do no harm should remain a central to the provision of high quality healthcare by putting the staff and patients at the core of all interventions, creating a culture of safety and implementing evidence-based policies. Lastly, introducing new innovative tools that promise newer ways to reduce harm as well as synthesise the main recommendations to health system policy and leaders (Angela et al., 2016)

Conclusion

This essay has focused on the adverse incident of Mr Jowett, for using root cause analysis and providing better solutions for improving practice. It has been highlighted as an important concern of patient safety for the managers and staff in healthcare settings. Finally, it represents some effective recommendations for healthcare policy makers on how to improve patient safety in near future.

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