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:

Latent failures

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

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’s³ 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

Rather than waiting for an adverse outcome, all mental health teams and mental health services should have an ongoing audit cycle asking questions about whether systems and processes are working. As a result of auditing, new procedures can be put in place which, hopefully, will reduce the likelihood of an adverse outcome. Despite best efforts, adverse outcomes will still occur. The immediate thought when adverse outcomes are considered is the death of a patient. However, adverse outcomes can include anything from the intervention not going quite to plan, to an unfortunate admission to hospital that could have been averted if the resources had been available, to a threat of an assault, etc. It is very important to review clinical practice, and that includes clinical risk management, at every opportunity and not only when the worst outcomes occur. This process should include:

Reviewing difficult cases where there were good outcomes will also improve risk management.

Personal structured reflection and review

It is difficult not to include the concept of blame, either of oneself or others, when reviewing a poor outcome. For practice to be reviewed effectively and objectively, the reviewing process should occur as far as possible in a confidential setting, where clinicians can be supported in exploring the event in detail without fear of recrimination. It is out of this type of process that improvements to clinical practice and changes to systems can occur. Team and clinical leaders should have these processes ready to go at all times, but clinicians should also be structuring this work into their everyday practice.

For example, when working in a crisis situation, after the problem has been resolved, it is good practice to spend a moment or two with your colleagues reviewing how it all went. Ask each other if your communication was good, if you would have done things differently at different stages, and if you would do it differently next time, etc. This creates better working relationships, improves communication and is a marvellous opportunity for reflection whilst the event is still fresh. If working on one’s own, utilising John’s model for structured reflection⁶

provides a template to follow. It is brief and easily applied and allows an exploration of the conflict and contradictions between what is practised and what is desirable. Figure 17.2 is an adaptation of the model which can easily be adjusted for group settings after critical incidents.

Figure 17.2 Model for structured reflection

Implementing change in both practice and systems after a reflective review based on this model is made easier as any change is based on understanding and not simply on emotion generated by the incident.

Team reviews

If the adverse outcome is one which does not require to be reported as a sentinel event, it should not simply be ignored but should be reviewed within the multidisciplinary team. Each team will have its own review process that they have decided upon. As described above, some teams choose to use John’s⁷ model adapted for group processes. These discussions should be carefully facilitated and the environment should be free of blame and supportive but as far as possible should explore the processes that lead to the adverse outcome. Figure 17.3 expands on the process of structured reflection and takes the review process into an analysis of systems issues.

Figure 17.3 Structured reflection and an analysis of systems issues

Service review, sentinel events and external reviews

Services will have different definitions of what a sentinel event is. Some services divide sentinel events into categories A, B and C. After a serious event, there is usually a requirement for services to review what happened, to learn from the experience and to mitigate future risk. Through these reviews, system and processes, improvements can occur. Dependent on the nature of the event and also on other factors, such as breach of professional codes, external reviews may occur.

Clinicians working in a mental health service should make themselves aware of the reporting requirements and review processes and policies.

As soon as practicable after an adverse event, a meeting should be called to determine ongoing service provision and to consider any management issues which may need to be addressed. These will usually include:

There should also be a ‘staff support — traumatic incident’ policy where the following interventions are available:

Clinicians will also need to be informed of the review process, who the review team is, and they will need to be informed that they can involve their respective indemnity insurers, union representatives and support person(s).

It is usual nowadays for the report from any review process to be made available to the patient/family and clinicians need to be informed of this.

Being involved in an internal or external review is not an easy process for any clinician. However, in a career working in mental health services, it is likely that this will be an experience which few clinicians will escape. Having some knowledge of the interview process and techniques can be comforting and reassuring. Below are some of the usual interview guidelines for the interviewer.

After an interview it is usual for a draft report to be released which should be read carefully for any factual errors.

These types of reviews increasingly take place in an environment of open disclosure. Open disclosure is a transparent approach to responding to an incident and/or adverse event that places the patient central to the response. This includes the process of open discussion and ongoing communication with the patient and their support person(s). An open disclosure approach also includes support staff and the development of an open disclosure culture where staff are confident that the associated investigations will have a quality improvement rather than a punitive focus.

After a death

The literature focuses mostly on the care and management of families subsequent to a suicide. However, the same general principles apply to other adverse outcomes. In recent times the practice of supporting the bereaved families of patients has become less common, possibly as a result of the fear of litigation. Avoiding survivors’ feelings of abandonment is an integral component of good clinical care and is also desirable, as further family suicides may follow the initial suicide. As well as being good practice, the offering of condolences, saying sorry and being supportive can substantially reduce the risk of further complaints. Saying sorry does not mean accepting blame. ‘Stonewalling’ many increase anger and grief.⁸ For bereaved family members to experience health practitioners as not caring after the death of a loved one tends to create an assumption that the health practitioner did not care to begin with. The provision of outreach to bereaved families is not only humane, but may be the best preventative measure against future complaints.⁹

The mental health worker should contact the family as soon as possible, preferably in person.¹⁰ The aim is to promote effective grieving, bearing in mind displacement of anger and other issues. Some families of patients who have committed suicide display hostility and the mental health worker needs to prepare for this. Open discussion in a private setting should allow the family to ask questions. Mental health workers need to remember that confidentiality continues beyond death.

Many mental health workers will not have been in this situation and, where possible, should be accompanied by a colleague with some experience of this work or with another worker who was involved with the patient.

The importance of continuing to document interventions even after a patient’s death should not be forgotten. This is still clinical work which needs to be recorded and communicated.