Patient safety, clinical governance
and risk management
Stuart Emslie
WHO consultant to KKM
Stuart Emslie
• Former academic, Strathclyde University, Scotland, specialising in
healthcare risk management
• Formerly Head of Controls Assurance for the National Health
Service in England, Dept. of Health
• Currently independent healthcare consultant specialising in
healthcare governance, risk management and patient safety
• World Health Organisation (WHO) consultant on clinical
governance, risk management & patient safety to Malaysian
Ministry of Health
• Visiting Fellow in healthcare governance and risk management at
Loughborough University, England – developed and leads parttime MSc degree in healthcare governance
• Visiting Lecturer, clinical governance, Oxford University Medical
School, England
• Visiting Lecturer, risk management & clinical governance, Flinders
University School of Medicine, Australia (China & Singapore)
• Advisor on clinical governance to Health Service Executive, Ireland
Objectives
• Understand ‘clinical governance’ (including
patient safety and risk management)
• Explore the Irish framework for ‘integrated
quality, safety and risk management’ as a
means of achieving ‘excellence in clinical
governance’
• Determine whether the Irish framework might
be worthy of adoption by KKM for public
hospitals in Malaysia and what modifications
to the framework would be required.
www.ministryofhealth.wordpress.com
MYR 75 billion - - - >100,000 employees
“Medicine used to be simple,
ineffective and relatively safe. Now it is
complex, effective and potentially
dangerous.”
Sir Cyril Chantler
Former Dean
Guy’s & St Thomas’s
Medical & Dental School
London
Technology Development and
Risk in Healthcare
Technology Development
Development
Risk Gap
Training
c1950
c1980
Source: Chris Quinn, Newcastle Hospitals NHS Trust, England
c2001
Time
Trend for Adverse Events, Start Date: 04/01/96
180
180
160
160
140
140
120
120
100
100
80
80
60
60
40
40
20
20
0
0
‘UK: blunders by doctors
kill 40,000 a year’
Sunday Times, 19 Dec 1999
“Medical error is the third most frequent cause of
death in Britain after cancer and heart
disease…….kills four times more people than die
from all other types of accidents.”
NB – USA approx. 98,000/year; Australia approx. 10,000/year
Hospital condemned over deaths
after 'appalling' failures in care
Health secretary apologises over damning
report on Mid Staffordshire NHS trust
17 March 2009
“Between 400 and 1,200 more
people died than would have
been expected at Mid
Staffordshire NHS foundation
trust over three years….
Although it is not clear how
many of these deaths could
have been avoided, the
Healthcare Commission said
patients undoubtedly suffered
as a result of lapses in the
standard of care.”
Mirror.co.uk
NEWS
Examples……
• Aintree Hospital – a tube that was helping the patient breathe
dislodged, causing a fatal heart attack and in separate
incident a chest drain being inserted to relieve pressure on
the lungs pierced the heart with “horrific” consequences
• Death of a patient at York given the wrong medication
• A missed diagnosis of meningitis led to a child’s death at East
Kent Trust
• At the Royal Hampshire County Hospital 23 patients died of
C.diff
• Five babies on the neo-natal unit contracted MRSA at
Winchester and Eastleigh
• A swab was left inside a patient’s abdomen after a caesarean
last June at Queen Mary’s Sidcup NHS Trust
• At East Cheshire NHS Trust a patient had the wrong part of
their body operated on
• etc.
From www.healthcaregovernance.info
Study
Year
No
hospitals
No case
records
Incidence
AEs
Incidence
prev AEs
Type of study
California
1975
24
20864
4.6%
0.78%
Insurance
NY State
1984
51
30121
3.8%
0.95%
Malpractice
UtahColorado
1992
28
14700
2.9%
0.93%
Compare NY
Australia
1993
31
14179
16.6%
8.4%
Quality
U.K.
(London)
1999
2
1014
10.8%
5.2%
Feasibility
Denmark
2000
17
1097
9.0%
3.6%
Pilot
N. Z.
(Auckland)
2000
3
1326
10.7%
4.3%
Feasibility
Canada
(Ottawa)
2002
20
3745
7.5%
2.8%
Quality
France
(Aquitaine)
2002
7
778
14.5%
4.0%
Quality
8.9%
3.4%
(Vict./S.Aust)
Average
Doctors v. Gun Owners
• Number of physicians in the US = 700,000
• Accidental deaths ‘caused by physicians’/year =
98,000
• Accidental deaths/physician per year = 0.14
• Number of gun owners in US = 80,000,000
• Number of accidental gun deaths/year = 1500
• Accidental deaths/gun owner =.0000188
• ?Conclusion - Doctors are approximately 7500 times
more dangerous than gun owners!
“Why do doctors kill more people than airline
pilots? Airline pilots are required to have time off
to sleep, do everything in duplicate and follow
protocols.”
British Medical Journal Vol 1 317 1998
ROOT CAUSE ANALYSIS
Improving the safety and quality of care
by investigating and analysing incidents
and issues to determine what went
wrong, why, and the actions necessary
to prevent recurrence
www.jcaho.org
“Improvement strategies that punish individual
clinicians are misguided and do not work. Fixing
dysfunctional systems on the other hand is the
work that needs to be done”
Saul Weingart, Harvard Executive,
Session on Medical Error and Patient Safety
Bristol Royal Infirmary
In the period from 1991
to 1995 between 30
and 35 more children
under 1 died after
open-heart surgery in
the Bristol unit than
might be expected had
the unit been typical of
other PCS units in
England at the time.
Clinical Governance
“A framework through which NHS
organisations are accountable for continually
improving the quality of their services and
safeguarding high standards of care by
creating an environment in which excellence
in clinical care will flourish.”
“… the framework through which
organisations influence the informal
psychological and social functioning of their
staff.”
"Clinical governance is the vital ingredient which will
enable us to achieve a Health Service in which the
quality of health care is paramount. The best
definition that I have seen of clinical governance is
simply that it means "corporate accountability for
clinical performance". Clinical governance will not
replace professional self regulation and individual
clinical judgement, concepts that lie at the heart of
health care in this country. But it will add an extra
dimension that will provide the public with guarantees
about standards of clinical care."
Dr Sam Galbraith MP
Minister for Health (Scotland)
June 1998
www.nao.gov.uk
and clinical decisionmaking based on up-todate evidence of
effectiveness
Including staff
continuing professional
development (CPD)
Source: Based on National Audit Office
Element Scores (%)
100
90
80
Score (%)
70
J
B
60
50
K
40
30
C
D
20
10
F
M
I
G
H
L
E
A
0
Element
Breakdown of responses
3%
2%
3%
18%
24%
Yes
H
M
L
18%
No
N/A
D/K
32%
Personal Work
Read the Framework document, have
a restful sleep and good breakfast, and
come prepared tomorrow morning to
do a self-assessment against the
Framework document as a basis for
moving forward over the next 2 days.