Stage 1 is horizontal evacuation from a subcompartment where the \201 re originates to an adjoining subcompart- ment or compartment. Stage 2 is horizontal evacuation from the entir e com- partment to an adjoining compartment on the same \202 oor, and Stage 3 is vertical evacuation to a lower \202 oor substan- tially remote from the \202 oor of origin of t he \201 re (at least two \202 oors below), or to the outside. Critical care evacuations are almost always practically limited to stage 1 or 2. Stage 3 ev acuations of the critically ill are particularly slow and dif \201 cult, and increase pote ntial mortality of patient and staff. If the \201 re is small, staff should make attempts to control the \201 re with equipment availa- ble, provided they do not endanger themsel ves or others in the process. There should be advance provision for horizontal evacua- tion procedures. These include availability of equipment stored within the critical care compar tment, ideally within the patient subcompartment. Such equipment includes ready-packed tran sportation equipment and drugs. Most critical care departments will already have this in th e form of a transportable transfer bag or pack for intra-hospital move- ment of patients. S enior clinicians will have the job of lead- ership within the intensive care team and makin g triage decisions. If an alert is activated indicating a \201 re in a nearby compartment , but not in the direct vicinity of intensive care, patients should be prepared for evacuat ion but not actually moved. Staff should ensure that all \201 re resistance barriers are closed and that automatic closure devices have functioned correctly to seal off the critica l care com- partment. Aspects of patient management may have to be changed to render moveme nt of the patient easier with least risk. This might include, for example, cessation of RRT or attempts at respiratory weaning. Transportation equipment and drugs should be gathered, checked and distributed to the patient bedside. Senior clinical staff should establish a r ank order for evacuation should this become necessary and make the coordinated plan clear t o all staff. Of note, with the most common cause of death in a \201 re being inhalation o f toxic gasses or fumes, patients connected to a closed ventilator circuit may be better pr otected than a self-ventilating patient for longer, and this should be taken into account w hen planning evacuation. In general terms, patients closest to the source, those self-venti lating and those least dependent should be moved \201 rst. Those whose evacuation would b e slow and where the patient \200\231s chance of survival may be signi \201 cantly comprom ised by movement may be best left contained in the hope that the \201 re will be containe d without the need for evacuation. Fire service response The \201 re service takes time to arrive, and its purpose is to con tain, limit or extinguish the \201 re for the purpose of pri- marily limiting personal in jury and loss of life, and second- arily minimizing loss or damage to the building. The res ponse time and the number of \201 re engines, or appli- ances, which are sent is pre-dete rmined and pre-agreed, depending on the assessed risk and location of the building. This is the pre-determined attendance. In a city center, the pre-determined attendance will usuall y require that three appliances attend, two within 5min, and a third within 8min. In a rura l area, the response must be one appliance within 20min. Evacuation and isolation procedures All staff should receive mandatory training on local Tr ust \201 re policies and procedures. The response to a \201 re should be a coordinated one between hospital staff, the nomi- nated local \201 re of \201 cer and the attending \201 re service. It is rare that any staff member has prior real experience of \201 re evacuation procedures; a smooth effective response is achieved by adequate training and a l evel-headed approach with clear leadership. The \201 rst step is alerting the local \201 re of \201 cers and activating the \201 re service. Most \201 res in health- care settings are \201 rst detected by direct observation rather Further reading NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-03: operational provisions Part L: NHS \201 re statistics 1994/5 \200\2232 004/5. 2007. NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-01: managing healthcare \201 re safety. 2006. 558 J COCKINGS NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-0 3: operational provisions Part F: arson prevention in NHS premises. 2006. NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-0 2: guidance in support of functional provisions for healthcare premises. 2007. NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-0 3: operational provisions Part G: Laboratories on Healthcare premises. 2006. NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-0 3: Operational provisions Part B: \201 re detec- tion and alarm systems. 2006. NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-0 3: operational provisions Part H: reducing unwanted \201 re signals in healthcare premise s. 2006. NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-0 3: operational provisions Part D: commercial enterprises on healthcare premises. 2006. Ridley SA, Parry G. Guidelines for \201 re safety in the intensive care NHS Estates. Firecode \200\224 \201 re safety in the NHS, Health Technical Memorandum 05-0 3: operational provisions. Part E: escape lifts in healthcare premises. 2006. unit. London: Intensive Care Society, 1998. This page intentionally left blank 560 A COHEN Legal issues and the Coroner be due to you having reported the case, being the respon- sible senior doctor, being mentio ned in an entry in the record or as a result of a comment from relatives or other witnesses . The Coroner \200\231s of \201 cer might ask to speak to you to discuss the case, but mor e commonly you will be asked by letter to provide a statement. Often the only informa- tion you are given is the name of the patient whose death is being investigated; consequently y ou may not know why you were approached for a statement or the reason it is required. The s tatement should be written in such a way that it tells of your involvement in the case. It is wise to avoid making comments that could be taken to be expert opinion except when neede d to explain your management. An experi- enced secretary will help format the statement in an ef \201 cient way, making it easier for the court to use. It is helpful to use paragrap h numbering. A doctor will often be asked to read their statement to the court providing ad ditional detail where necessary, so arranging it in a chronological way is helpful. It is i mportant to avoid the use of excessive jargon while not explaining every minor detail in a condescending way. An intensivist may be asked for a statement when the event of concern oc curred prior to the patient arriving in the ICU. This is to help the Coroner establish the sequence of events leading up to a death. Senior intensivists who are familiar with the sys tem can be helpful to the Coroner by explaining that the care on an ICU is team based and t hat although their personal involve- ment in a case was minimal, they have generated a repo rt and present evidence using their own knowledge and information from the records. This pr agmatic approach saves each team member having to provide a report and attend court. It wou ld be advisable for inexperienced doctors to obtain assistance with a Coroner \200\231s rep ort. This can be obtained from senior colleagues, the Trust legal or risk management depart ment or the doctor \200\231s defense organization. If there is any suggestion that the acti ons of an individual doctor are being called into question, then they should seek the advic e of the body that represents their interests. This is their defense organization. Doctors working in intensive care need a knowledge of the law in a number of circumstances such as: \200 Working with HM Coroner \200 reporting a death \200 witness of fact \200 organ donati on Contact with the police Civil action \200 \200 Consent End of life decision making \200 \200 \200 \200 as party to a civil action as expert \200 futility autonomy assisted suicide A doctor has a duty to be aware of regulations relating to clinical practice such as the re cording and use of controlled drugs. They may need legal advice when in court, appearing in front of the GMC and in dealing with ethical issues arising in clinical practice. The GMC document \200\230Fitness to Practice \200\231 lays down guidance for all doctors. Some of the guidance relates to legal and ethical issues. It is continually under review, and docto rs should be familiar with it. The Coroner Reporting a death to the Coroner A death certi \201 cate has to be issued prio r to disposal of a body. When a doctor has been caring for a patient during a terminal illn ess, he is responsible for issuing a certi \201 cate. Under certain circumstances, it woul d be usual to discuss the case with the Coroner rather than issue a certi \201 cate. Somet imes the need to discuss the case is clear, such as violent deaths and deaths related to ne glect, but other situations may be unclear. Local practice concerning the amount of time be tween admission or surgery and death can vary. Coroner \200\231s of \201 cer It is unusual to discuss a case with the Coroner personally; \201 rst contact is more likely to be with a Coroner \200\231s of \201 cer. This will b e an experienced police of \201 cer who works closely with the Coroner. It is always safer to discuss a questionable case with the Coroner \200\231s of \201 cer, who can be relied upon to be a source of useful information, than to put the patient \200\231s family at the inconvenience of a certi \201 cate being rejected when presented to the registrar. It does not take long to become familiar with local practice following a few of these discussions. Coroner \200\231s post-mortem Following a discussion with the Coroner \200\231s of \201 ce r, a doctor may be asked to issue a death certi \201 cate. If the doctor does not feel abl e to issue a certi \201 cate or the Coroner is unhappy with the suggested entry, then the Coroner will take over the case. When there is con \202 ict between the hospital and berea ved relatives about any aspect of care, it is worthwhile discuss- ing concerns with the Cor oner, who may take over the case at this stage to avoid future problems. Once the Coroner t akes on the responsibility for a case, he may arrange a post-mortem. If relatives are unhap py to have a post-mortem, it remains for the Coroner to con- sider the issues and make what ever arrangements he feels necessary. The Coroner \200\231s pathologist is usually happy fo r clinical staff to attend a post-mortem as they can be a useful source of information abou t the circumstances preceding the death. If a clinician is not present during the examinati on, Possible mishap resulting in death When an intensivist suspects that an error in patient ca re may have resulted in admission and ultimately death, they must ensure correct procedures are followed by informing the Coroner as well as relevant personnel within their organizat ion. They must also remember their responsibili- ties laid out in the GMC \200\231s Good Me dical Practice. It is generally more useful for the Coroner to be contacted by the member o f the clinical team most familiar with events of concern. Coroner \200\231s witness statement During the investigation of a death, the Coroner might become aware of your involvement in the case. This could 561 CHAPTER 33.8 Legal issues and the Coroner unable to give consent or refuse, then the doctor \200\231s respon- sibility to the patient may be over-ridden if \200\230there are grounds for believing that this is the public int erest or disclosure is required by law \200\231 (see Further reading) then the results of the post-mortem will be unavailable prior to an inquest. Coroner \200\231s inquest The Coroner often opens and adjourns a preliminary inquest to all ow formalities relating to identi \201 cation of the body to be considered, facilitating r elease of the body for disposal. The full inquest is then held some time later at the conve nience of the Coroner. Prior to the inquest there will be a request for details of the doct or \200\231s availability. The court is not interested in routine clinical appointments but will take notice of dif \201 - cult to reschedule commitments such as foreign travel. If necessary, the Coroner can insist on attendance. A Coroner \200\231s inquest is often the \201 rst time a doctor enters a court. There are significant differences between an inques t and a trial. An inquest is an enquiry into how the deceased died; there is no defendant a nd it is not about attributing blame. There is often a single court reporter present but im por- tant cases will attract interest from larger numbers of the press. Due to the widely v ariable nature of Coroners \200\231 courts, doctors should be prepared to \201 nd themsel ves coming across relatives of the deceased around the court building prior to and after th e case. When called to give evidence, the doctor will be questioned first by the Coroner an d then by representatives of the relatives or other interested parties, which could include the doctor \200\231s own legal team. Any of the interested parties may have a solicitor or barrister in court. The Coroner should not permit inappropriate questioning, but it is vit al to indicate clearly if you cannot answer because you are unaware of the facts or you are being asked for an opinion outside of your area of expertise. Following your evidence, you may be given permission to leave the court. Be warned \200\224if you remain it is much eas ier to recall you. There are a number of possible verdicts following an inquest, such as na tural causes, unlawful killing, accident or misadventure (another way of saying accident). After delivering a verdict, the Coroner may take matters further by communicating concerns to a responsible body or referring a case for potential criminal proceedings. Civil actions Any doctor in clinical practice is at risk of becoming involved in a civil ac tion. The complaint may or may not have originally been directed at the intensive care comp o- nent of a hospital stay. The direction of a claim can change as the litigation progresse s. Much has been done in recent years to speed up the process and reduce the confronta- tio nal nature of civil actions. Most doctors involved in these actions say how stressful the e xperience is. The best way to protect yourself is to become familiar with the system so you can more effectively in \202 uence proceedings. Complaints Often things start to go wrong when a complaint is received about patient care. The best way to deal with this is to talk to the complainant and be honest and open. In an attempt to make complaint handling appear important, most Trusts commit themselves to respo nse letters being rapidly dispatched and signed by a senior of \201 cer. A \201 nal lett er responding to a complex complaint is likely to be a montage of uncoordinated responses f rom clinicians. Relatives receiving such a letter not infrequently consider the response to be a deliberate process of deception and seek legal assistance to have questions answered. Consultation with solicitor Medical negligence cases can follow a number of different paths . Once a medical negligence solicitor considers there is a case to answer, he will request that the Trust release the records. He may also give the hospital the opportunity to provid e additional detail about patient care. Limitation Generally a medical negligence claim will only be heard if the proceedings comme nce within 3yrs of the claimant becoming aware of a potential claim. Expert advice Prior to proceeding, the solicitor will seek expert advice. On the \201 rst attempt they may not instruct the correct expert, but eventually one will be found who can comment authoritatively on the merits of the case. Experts are usu- ally instructed separa tely by claimant and defendant, but their reports should be non-partisan and directed to th e court. The report must contain a declaration making this clear. Following expert review, the action may be terminated because either the client accepts advice that the case is like ly to fail or those funding the action withdraw support. Organ donation The principle of brainstem death and testing is well recog- nized. Coroners need to be involved where a death is vio- lent or other circumstance in which a death would be reported. The local transplant coordinator will be able to provide advice relating to o rgan donation and can facilitate contact with the Coroner if necessary. The human tissue Ac t 2004 made a number of changes that affect the process of organ donation, such as de \201 ning suitable qualifying rela- tionships for those providing consent. Experience improves donation rates, and coordinators will make themselves available to help with the consenting process if required. They can also advise on practical problems relating to brainstem dead or NHBDs. Letter of Claim If the claim is to proceed a formal \200\230Letter of Claim \200\231 is co nstructed and sent to the Trust detailing aspects of care that are being questioned. The Tr ust will then instruct its own legal team who will investigate the case and consult its own experts to deter- mine how the allegations should be defended. The doctor, patient and the police At times the interests of patients, doctors and the poli ce may clash. The GMC advises that doctors have a duty of care to their patient as a prime responsibility, but that they are also expected to act as responsible citizens. When the po lice request access to patient information, it would be usual to seek patient consent. When patients are Conferences A lot of decision making by both claimant and defense teams will be in conferen ces of solicitors, counsel, experts and involved parties. In this environment, barristers m ay explore the experts \200\231 opinions, help establish additional 562 A COHEN medical team of the patient \200\231s wishes. Doctors are bound to respect a patient \200 \231s autonomy or right to self-determination. Assuming there is no reason to question info rmation provided by relatives, this could help the clinical team devise a treatment plan th at respects the patient \200\231s autonomy. In the case of young children, parents can give or withhold consent. If there is con \202 ict between the clini- cal team and relatives, it is possible to ask the court for advice. If the issue relates to a child where consent i s being withheld for a treatment considered in the best interests of the child, the clinica l team has no choice but to apply to the court. information that is required and ultimately form a view of the chances the case might succe ed. Defense Eventually unless the case is to be settled, the Trust will produce a formal defens e explaining events and admitting or denying allegations that have been made. Timing The conduct of the case such as the time allowed to pass between each of these proce sses is carefully controlled by the court. Meetings of experts Expert opinions often differ. When this is important to the case, the c ourt will instruct that the experts meet for a discussion. Experts are asked to produce a j oint report in response to an agenda agreed between instructing solicitors. It is frequentl y possible for cases to be settled following the meeting of experts. End of life decision making Futility If a treatment is not going to help a patient, then it is inappropriate to continue with it. There is no single critical care scoring system desi gned to predict outcome in an individual, so each decision must be taken by assessing the p atient on their merits. It is good practice for decisions of this nature to be shared by an other senior doctor and supported by the team and the patient \200\231s relatives. It may b e necessary to allow time for the futility of the situation to be realized. Ideally relativ es will be left with the feeling that they have been consulted and their views considered w ithout considering that it was their decision to limit or withdraw therapy. Witness statement Once a claim has been brought, it can be many years before it reaches cou rt. If you feel there is a chance that you will be called upon to give evidence in a civil action, it is worth- while making a record for future review. This may take the form of an entry in the patient record. Any such entry should be accurately dated and timed. Alternati vely, it is reasonable to write an account for your own \201 les. If you use a formal sty le, it may be accepted later by the court, if you wish. Patient autonomy Patients have a right to accept or refuse treatment. It is important for t he clinical team to be sure the patient is of sound mind and not undergoing any form of coe rcion. If this is the case, then a patient has the right to refuse treatment even though th is may result in death. As in other cases involving end of life decisions, it is helpful fo r senior doctors to have support for their actions from colleagues or the courts if necessa ry. Failure to honor a patient \200\231s right to refuse treatment has resulted in a judge criticizing intensivists. Court Many cases are settled between parties prior to appearing in court. If a settlement c annot be agreed, then a trial will be held. During the trial, a judge will be called upon t o assess the merits of the case and to determine the amount of any damages. Providing expert opinion Intensivists are frequently asked for expert opinion. Any experien ced clinician who has been instructed in the workings of the legal system can act as an exp ert. The responsibilities of an expert are onerous. Advice must be given within the expert \200\231s area of expertise. Opinions must be full and frank, and directed to the court irr espective of the side that is providing instructions. Experts must be reliable and make the mselves available to support an ongoing case. English law is in \202 uenced by precedent o r previous court decisions. For example, a doctor is considered to have acted in a reasonab le way if there is a body of opinion that would have acted in the same way. This is called the Bolam test after the trial where the precedent was set. Even though many precedents hav e been set, there is a need for lawyers to interpret them. For example, the Bolam princi- p le will not apply if the judge considers that the actions of the body of opinion in questio n are not logical. Assisted suicide The law sees no resemblance between withdrawing life- saving treatment and agreeing to help a patient commit suicide, even if such a patient has a terminal condition . Assisted suicide is illegal. It is increasingly important for doctors working in intensiv e care to have an understanding of the law relating to their practice. They should always b e prepared to seek legal advice when issues are complex. There may be times when a doctor w ould be best advised by a lawyer instructed on their behalf. Generally this advice would be from their own defense organization. Further reading Braithwaite M. Law for doctors \200\224principles and practicalities. RSM London: Press Ltd. 2000. General Medical Council. Withholding and withdrawing life- prolonging treatments: good prac tice in decision-making. Appendix A: the legal background. London: GMC, 2002. Consent Generally it is not possible for an individual to give consent to treat an incompet ent adult. Doctors are expected to consider the patient \200\231s best interests. It is goo d practice to keep close relatives informed of events and to encourage their support for th e management plan. The next of kin may be able to contribute to patient care by informing t he Singer P. Ms B and Diane Pretty: a commentary, J Med Ethics; 2002; 28: 234 \200\2235. What happens if the patient refuses to talk to the police, or the patient is unconscious? h ttp://www.gmc-uk.org/guidance/ current/library/reporting_gunshot_wounds.asp#1 This page intentionally left blank 564 J BION Patient safety Introduction Patient safety is now recognized as a major healthcare issue. The Institute of Medicine \200\231s report in 2000 estimated that between 44 000 and 98 000 patients in the USA might die each year from what was termed \200\230medical error \200\231. Other countr ies report similar rates of error and avoidable harm, and many have established national ag encies for patient safety coordinated by the World Health Organization \200\231s World Alli ance for Patient Safety. The narrow de \201 nition of safety as \200\230avoidance of harm \200\231 should be broadened to include reliability of care \200\224the right actions at t he right time to the right patients. Error is a problem for the entire healthcare system, n ot just for the terminal point in the chain of causation \200\224the front-line doctors and nurses charged with the responsibility of making unsafe systems safer. Reducing error and improving reliability require changes in behavior and attitudes as well as resources; these changes must be focused on processes of care, teamworking, com- munication, partnership wi th patients, and life-long learning through competence assessment. note review is laborious, subject to hindsight and interpre- tation bias, and relies on goo d note-keeping. Process meas- ures rather than outcome are better for performance managemen t, but require rapid feedback of data to the user. The fact that nurses and (to a lesser ex tent) junior doctors are the most likely to report error, and that nurses are major \200 \230error interceptors \200\231 suggests the need for work- place-based data collection at the point of care, integrated Table 33.9.1 De \201 nitions of commonly used terms relating to patient safety. Term De \201 nition Accident An event which damages a de \201 ned system and disrupts the continuing or future output o f that system. A set of interdependent elements, human or non-human, which interact to achi eve a common aim. The failure of a planned action to be completed as intended (execution er ror), or the use of a wrong plan to achieve an aim (planning error). Errors of commission a re faulty actions; of omission, faulty inactions. Wrong action plan properly conducted, res ulting in an unintended outcome Execution errors in which the action performed differs from that intended. Slips are observable, lapses are not. A fault in performance at the level o f the operator. A fault in design, installation, management or maintenance which may subseq uently result in harm. System Error Taxonomy Comparisons between publications are made more dif \201 cult by the variety of te rms and methods used in safety research. A selection of de \201 nitions is offered in Tabl e 33.9.1. More are available from: http://psnet.ahrq.gov/glossary.aspx Mistake Slip or lapse Epidemiology and impact Reported rates of error and harm vary. Most errors do not cause har m, and most go unreported. Retrospective case note reviews are particularly susceptible to observer bias and interpretation; they rely on detecting adverse events, and then making a value judgment about avoidability. The classical Harvard and Australian studies reported ad verse event rates of 3.7 and 16.6%, respectively, of which 69 and 51% were considered avoid able. Prospective observational studies suggest higher rates, with adverse drug events bein g the most common. Harmful consequences include emo- tional and physical suffering, and \201 nancial costs; hospital- acquired infections alone affect 2 million patients and caus e 90 000 deaths in the USA at an estimated additional cost of US$5 billion per year. Physi cians, patients and the public want safer systems. Acutely and critically ill patients, the elderly and longer stay patients are most susceptible to error and its consequences. In th e ICU, errors affect 20 \200\22330% of admissions, of which around half are avoidable; of t hese, a fourth cause signi \201 cant harm to the patient. Reported daily error rates vary from 0.18 to 1.7 per patient, and adverse events from 13 to 40 per 1000 patient days. Active error Latent error Critical incident A pivotal event with the potential to cause an adverse event. An injury caused by medical management that resulted in measurable disabi lity. A preventable adverse event caused by medical management which did not meet the stand ard of care expected of that practitioner. Systematic risk analysis of how failures occur, and their consequences. Facilitates prioritization of risk, and methods of prevention. Illn ess or injury caused by doctors. Often misused to mean \200\230healthcare-related \200\231 . Freedom from accidental injury. The avoidance, prevention, and amelioration of adverse ou tcomes or injuries arising from the processes of health care. A process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system. A process for identifying the most basic or causal factor or factors that unde rlie variation in performance. Independent elements contributing to desired outcome. Any un anticipated event in a healthcare setting resulting in death or serious physical or psychol ogical injury unrelated to the natural course of the patient \200\231s illness. Adverse event Negligent adverse event Failure modes effects analysis Iatrogenic disease Patient safety Patient safety practice Detection and monitoring Effective detection, reporting, and taking action to learn from an d prevent error requires a patient-focused culture throughout the organization. There are m any methods but no single solution for detecting and reporting error, and the precise instr ument used depends on the use to which the data will be put. Patients \200\231 or relatives \200\231 complaints are important (the majority refer to suboptimal communication with sta ff), but imprecise and delayed. Adverse event reporting means that harm may already have oc curred. Critical incident reporting suffers from selection bias. Retrospective case Root cause analysis Redundancy Sentinel event 565 CHAPTER 33.9 Patient safety in routine activities and clinical decision support, and linked to professional development . Causation High reliability organizations recognize that systems must support individuals to prevent error (Fig. 33.9.1). Every individual in an organization must share the same goa ls. Two of the most reliable services, blood transfusion serv- ices and anesthesia, have lo ng-established systems of process control, safety checks and (in most countries) well struc tured systems of supervision, training and education, resulting in reliability levels appro aching 4 \200\2235 sigma, but still well below perfection (6-sigma, 3.4 defects per million opportunities). Common causes of error include active failures at the level of the individ ual (e.g. to apply knowledge, communication problems, technical incompetence) combined with latent conditions in the individual (fatigue, illness, attitudinal prob- lems) or the syst em (working environment, poor organiza- tion). It is usually the combination of the two whi ch results in patient harm. Errors of commission are generally easier to detect (IV adminis tration of concentrated potassium solution causing cardiac arrest) than errors of omission (failure to correct hypokalaemia in a septic patient, con- tributing to AF, low cardiac out put and MOD). Errors of omission may be more important, however, as they may also re \202 ect a lack of care. which is why safety is better subsumed under reliability. There are six elements for improv ing reliability: \200 \200 \200 \200 \200 \200 Standardization Simpli \201 cation Redundancy Teamworking and communication Partnership Ed ucation Application of these principles has been shown to reduce bacteraemias associated with centr al venous catheters effectively to zero. Standardization: medical staff are better at creat ing guidelines and protocols than implementing them in their own practice. Individual varia tions in clinical practice increase the opportunity for error. The Surviving Sepsis Campaig n provides an example of evaluating evidence and formulating clinical guidance. Simpli \201 cation: reducing complexity minimizes opportunity for error by removing additional or unfamiliar steps in the processes of care, e.g. by reducing the number of hando- vers ( \200\230hand-offs \200\231) and using common forms of information transfer. Sepsis Care Bun dles simplify by aggregation. Electronic prescribing systems with forcing functions limit c hoices to correct actions. Redundancy: means more than one way of achieving the correct goa l. This includes reminders, prompts, multiple communication channels and empowering team me mbers to draw attention to errors, and adequate staffing to reduce fatigue. One approach is to ask the question \200\230what are the main safety risks for this patient today? \200 \231 Effective teamworking and communication: encourages group participation, mutual perfor mance monitoring,and explicit daily goals (e.g. on the ICU chart), as well as making time f or listening to others. Partnership: means shared goals. For example, involving close relat ives in the bedside ward rounds can enhance shared purpose, enable families to feel that th ey are Management and prevention When error results in harm, we have two professional responsibili ties. One is to provide appropriate care for the victim(s) \200\224the patient, the family and the staff involved. The second is to learn from the episode and to take steps to minimi ze the risk of repetition. This requires transpar- ency, honesty and a supportive environme nt. Structured methods of investigation make it easier to learn from defects in healthcare and impose a necessary discipline on the less effective morbidity and mortality meeting. Pr evention is the essence of safety improvement efforts. However, too narrow focus on safety may have the unintended consequence of impeding ef \201 cacy of care, organizational & CORPORATE CULTURE CONTRIBUTORY FACTORS INFLUENCING PRACTICE CARE DELIVERY PROBLEMS defenses/ BARRIERS Work/environment factors Unsafe acts Team factors Management decisions and organizational processes Errors Individual (staff) factors Incident Task factors Violations Patient factors LATENT FAILURES ERROR & VIOLATION PRODUCING CONDITIONS ACTIVE FAILURES Fig. 33.9.1 A systems approach to analyzing accidents (from Woloshynowych et al., 2005). 566 J BION contributing to care and improve the accuracy of informa- tion \202 ows. Education: in th e clinical environment, safety, reliability and teamworking can be included in simulation-b ased learning. Learning from error must be embedded in undergraduate and postgraduate natio nal training programs (see www. cobatrice.org) and integrated across disciplines and over p rofessional lifetimes. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. W ashington, DC: National Academic Press, 2000. NICE guideline. Acutely ill patients in hospital: recognition of, and response to, acute il lness in hospitalized adults. National Institute for Clinical Excellence 2007. http://www.n ice.org.uk/ CG50 Patient Safety Observatory. Safer care for the acutely ill patient: learning from serious i ncidents. National Patient Safety Agency 2007. http://www.npsa.nhs.uk/health/resources/pso Reason J. Latent errors and system disasters human error. Further reading Bion JF, Heffner J. Improving hospital safety for acutely ill patients. A L ancet quintet. I: Current challenges in the care of the acutely ill patient. Lancet 2004; 3 63: 970 \200\2237. See also the subsequent four articles in this \201 ve-part series. Cambridge: Cambridge University Press, 1990. Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: the incidenc e and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005; 33: 1694 \200\223700. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med 2002; 347: 1933 \200\22340. Weingart SN, Wilson RMcL, Gibberd RW, et al. Epidemiology of medical error. BMJ 2000; 320: 774 \200\2237. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospit alized patients. N Engl J Med 1991; 324: 370 \200\2236. Woloshynowych M, Rogers S, Taylor-Adams S, et al. The Investigation and analysis of critica l incidents and adverse events in healthcare: a review of the literature. Health Technol As sess 2005; 9: 1 \200\223143. http://www.who.int/patientsafety/en/ This page intentionally left blank 568 R MORENO & S AFONSO DE CARVALHO Severity of illness scoring systems The evaluation of severity of illness in the critically ill patient is made through the use of general severity scores and general outcome prognostic models. 1 Severity scores are in struments that aim at stratifying patients based on their severity, assigning to each patie nt an increasing number of points (or score) as their sever- ity of illness increases. Organ failure is not a static process and the degree of dysfunction varies with time during the course of disease. The variables chosen to evaluate each organ need to be objective, s imple and available but reliable, routinely measured in every institution, speci \201 c to the organ in question, and independent of patient variables, so that the score can be easi ly calculated on any patient in any ICU. 2 Prognostic models usually use a given set of prognostic variables and a certain modeling equation. aim to stratify patients according to their seve rity of illness based in their respective risk aim at predicting a certain outcome \200\224 usually the vital status at hospital discharge. There is no general agreement about how to assess organ dysfunction effectively, but all th e widely used systems include six key organ systems (cardiovascular, respiratory, hematolog ical, central nervous, renal and hepatic), evaluated through a combination of physiological (e.g. PaO2) and therapeutic (e.g. use of vasopressor agents) variables. Commonly used orga n dysfunction/failure scores are the Multiple Organ Dysfunction Score (MODS). the Sequentia l Organ Failure Assessment (SOFA) score and The Logistic Organ Dysfunction System (LOD) sco re. Usually these scores, describing a patient \200\231s progress, are registered at admiss ion and then once a day until ICU discharge. Several derived measures are often computed su ch as the maximum score or the delta (maximum minus admission) score. In Europe, the SOFA s core is popular. It evaluates 6 organs/ systems, with each scoring between 0 and 4. Zero is normal, 1 \200\2232 dysfunction and 3 \200\2234 failure. Individual organ function can thu s be assessed and monitored over time, and an overall global score can also be calculated ( see Table 33.10.1.