Managing adverse outcomes

Published on 24/05/2015 by admin

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Last modified 24/05/2015

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Chapter 17 Managing adverse outcomes

Adverse events usually originate at a variety of systemic levels: the patient–clinician interaction, the team, the working environment and the organisation. Consideration of all of these factors is required when investigating and preventing adverse outcomes. The liability to make an error is strongly affected by the context and conditions of work, and the chain of events leading to an adverse outcome is usually complex. The root cause may be in several interlocking factors such as the use of locums, communication problems, supervision problems, excessive workload, resource limitations and training deficiencies. Analysis of accidents/adverse outcomes in mental health should explore not just the individual factors but also pre-existing organisational factors.

This process of review is usually called a root cause analysis. Root cause analysis is defined as a systematic iterative process whereby the factors which contribute to an incident are identified by reconstructing the sequence of events and repeatedly asking ‘why?’ until the underlying root causes (contributing factors/hazards) have been elucidated. Once this has occurred, changes can be made to whichever systems were found to be problematic.

There are 2 types of errors leading to adverse outcomes:

1. active failures

2. latent failures.

Active failures

Active failures are those acts or omissions committed by individuals that have an immediate adverse consequence. Where possible, failsafe mechanisms are brought in to guard against human error; for example, sharps boxes or computerised prescribing programs that do not allow excessive doses to be prescribed. Active failures can be divided into three subgroups:

1. Action slips or failures, such as labelling the wrong blood sample. Departure from routine is a major factor in the absent-minded slips of action.¹

2. Cognitive failures, such as memory lapses or making mistakes through ignorance.

3. Violations which are deviations from usual operating practice without good reason. These are more likely to occur secondary to low morale, poor modelling from senior staff or inadequate management.

Latent failures

Latent failures provide the conditions in which adverse events occur and are the responsibility of all clinicians and managers. They include:

• heavy workloads

• inadequate knowledge

• inadequate supervision

• stressful environment

• rapid change within an organisation

• inadequate systems of communication.

These are the factors that influence staff performance and may precipitate errors and affect patient outcomes. The process of latent failures increasing the likelihood of active failures can be shown diagrammatically (see Figure 17.1).² The latent failures are transmitted along various organisational and departmental pathways to the workplace where they create local conditions that precipitate errors and violations. This model creates a more complicated picture where the environment in which an adverse event occurs is one where many factors are added, one to another, before the accident happens. Minimising the likelihood of adverse events occurring requires attention at all these levels by all staff, from the most junior to the most senior.

Figure 17.1 The multifactorial pathway to accidents

For senior professional staff, the task of creating an environment where errors are reduced can seem daunting. Regular auditing of compliance with guidelines and procedures is a useful start. The presence of a risk management team for the mental health service can be of immense use. The risk management team can review incidents, compile themes of recurring incidents and look for causes of errors and adverse events. When this is given in the form of feedback to staff, the cycle of reviewing risk is complete. Reviews conducted sensitively, in an environment in which healthy enquiry and no blame occurs, enable staff to participate fully and make maximum use of the experience.

Reviews of this type can benefit from the use of reflective practice at a group level. Using John’s ³ model or Rolfe’s et al (2001)⁴ and asking the questions within a group setting reduces the likelihood of blame occurring and can give a framework for exploring adverse outcomes.

Finally, a summary of error producing conditions ranked in order of increased likelihood of the event happening can be sobering (see Table 17.1).⁵

Table 17.1 Ranked summary of error producing conditions

Condition	Risk factor
Unfamiliarity with the task. Time shortage. Poor human system interface. Misperception of risk. Inexperience — not lack of training. Poor procedures. Disturbed sleep patterns. Monotony and boredom.

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