After reading this chapter you should:
be able to apply patient safety thinking
understand how human factors detrimental to care can be minimised
be able to lead a safe and effective handover
This term describes the framework of practice that ensures patients receive the highest possible care from the NHS. All staff—whatever their role and whatever their grade—are required to contribute to the continued improvement in the quality of individual patient care. This can be achieved through staff education and development, continuous review of practice, a culture of openness and honesty on practice issues and full and clear communication with individual patients.
Practical aspects of clinical governance
This can be achieved by ensuring that the care provided is, where possible, based on sound evidence from research and subsequently improved through audit and performance review. The National Institute for Health and Care Excellence (NICE) provides national guidance on the prevention and treatment of many conditions after reviewing all available evidence. All published information is reviewed and updated at regular intervals.
High-quality patient care requires the skills, experience and training of many individuals. This is best achieved by incorporating staff into multidisciplinary teams and ensuring that all members communicate effectively on behalf of the patient.
This is part of the process of reviewing the clinical performance of a team and is now well-established in clinical care. Audit requires the identification of important standards of excellent practice, review of the practice of the team against those standards, the presentation of results to the relevant teams and introducing a change in practice to ensure all meet the standards.
Near misses and mistakes
Clinical practice is complex and difficult and sadly mistakes do occur. The impact of any mistake can be devastating for the patients and families and can also impact on clinicians involved. It behooves all clinicians to strive to avoid mistakes in their practice but if they do occur, it is then the responsibility of the clinicians and the institution to help understand and explain the issue. There is no place for hiding, disguising or obfuscating the events. Being open and honest is hard to do but it does benefit all involved. The law on Duty of Candour has already been presented ( Chapter 32 Ethics and Law) and clearly indicates that any attempts to hide the truth constitutes a criminal offence.
The term ‘clinical incidents’ is used to describe any event relating to the patient and his or her clinical care which results in harm, or which could have led to harm had the events been allowed to progress. Clinical incidents—actual or potential—must be reported to the institution for assessment so that clinical risks can be identified and reduced. Such clinical incident reporting is not part of a disciplinary process and team members are encouraged to view it as part of a reflective system that supports improvement.
All institutions provide opportunities for patients and families to submit comments and complaints on any aspect of the care they receive. Although complaints can be difficult to receive by the individual or team, it is important to recognise that they may highlight an aspect of care which does not meet the needs of patients and which is not recognised by team members. They should be seen as an opportunity to learn about the impact of practice on the care provided. All hospitals have a Patient Advice and Liaison Service (PALS) which offers confidential advice, support and information on health-related matters to patients and families and can often act as an intermediary in some situations.
ensure patient is safe and effects of incident addressed immediately
ensure ongoing review of patient
inform senior colleague
be honest with patient and family in a timely manner
apologise for events and avoid blaming individuals
record details of event fully in notes—including date and time of event
record details of discussions with patient and carer
complete a clinical incident form
• support any assessment process
The process which looks at clinical situations and tries to identify possible problems before they occur. It recognises that in complex care, there are many areas where errors are made and a review of practice aims to break down the process to component elements and identify potential problems. Having identified any areas where the safety of the patient—or staff—could be compromised, it is then possible to introduce checks of, and changes to, practice so as to minimise or remove risks in care.
It is important to ensure that patients and their carers have an understanding of the various aspects of the care being provided to them. Knowledge and understanding of the problem, the management options and the potential outcomes are all important for the patient and will reduce the fears and worries brought about by ignorance. It is imperative that members of the MDT take time to address these concerns and present the information in an understandable manner that is devoid of jargon. It is also imperative that effective verbal and written communication takes place between members of the MDT.
Children and adults diagnosed with acute lymphoblastic leukaemia receive multiple chemotherapy drugs orally, intravenously (IV) and intrathecally (IT).
Historical protocols required the administration of intrathecal methotrexate and intravenous vincristine on the same day. Sadly, there were some patients who were erroneously given vincristine intrathecally and died from vincristine neurotoxicity.
Following one such event, the Chief Medical Officer in the UK appointed an external and independent assessor to look at the events surrounding the practice. Evidence was taken and the series of events which led to the death of a patient following vincristine given into the intrathecal space were reviewed in detail. National mandatory guidelines were produced and strict changes to practice were required in all centres providing intrathecal chemotherapy. These included:
only approved centres treating appropriate numbers of patients allowed to administer IT chemotherapy
national protocol changed so IV vincristine and IT methotrexate to be given on separate days
only fully trained medical staff to prescribe IT chemotherapy
only fully trained pharmacy staff allowed to dispense IV and IT chemotherapy
only fully trained staff in designated centres allowed to administer intrathecal drugs
all intrathecal needles in the institution use connector which is incompatible with standard syringe fittings
drugs for intravenous administration dispensed in syringes incompatible with intrathecal needle connector or in infusion bags
These changes and others were introduced and aimed to remove all risk to patients receiving treatment.