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Safety Data for Safer Care From the Patient Perspective. Margaret Murphy Patient Advocate Member, Patient for Patient Safety Steering Group WHO World Alliance for Patient Safety. INTRODUCTION. Personal Background & Motivation

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safety data for safer care from the patient perspective

Safety Data for Safer Care From the Patient Perspective

Margaret Murphy

Patient Advocate

Member, Patient for Patient Safety Steering Group

WHO World Alliance for Patient Safety

introduction
INTRODUCTION
  • Personal Background & Motivation
  • Learning from the Patient Experience – the mismatch between the actual and the ideal
  • Non-compliance
  • - when guidelines, processes and best
  • practices are not observed
  • Quality communication
  • Effective communication
  • Data collection in relation to the above
  • - data validation;
  • - confirming the reliability of sources
slide5
8 Days
  • before
  • admission
  • to
  • hospital
the questions
The Questions
  • Simple questions…..
  • Why did Kevin die?
  • What went wrong?
  • - we need to know and we need to understand -
court ruling
Court Ruling

“It is very clear to me that Kevin Murphy should not have died.”Judge Roderick Murphy at High Court RulingMay 2004

the unfolding story 1997 1999
The Unfolding Story 1997-1999
  • Persistent back pain – GP Visits, X-Rays
  • Orthopaedic Surgeon – Bone Scan, Blood Tests
          • 1997 1999
  • Calcium 3.51 (2.05-2.75) 5.73 (6.1)
  • Described as ‘inconsistent with life’.
  • Creatinine 141 (60-120) 214
  • Urate 551 (120-480) 685
  • Bilirubin Direct 9.9 (0-6)
  • Alk Phosphate 489 (90-300)
peer review
Peer Review

“The combination of bone pain, renal failure and hypercalcaemia in a young patient points either to a diagnosis of primary hyperparathroidism or metastatic malignancy and these ominious results should have been investigated as a matter of urgency”.

“All evidence indicates that the patient was suffering from a solitary parathyroid adenoma and removal would have been curative with a normal life expectancy”

“Kevin would have had surgery to remove the over-active parathyroid gland. He would have been cured and would still have been alive today.”

Research : 96% Success; 1% Complication

the shortcomings
The Shortcomings
  • Inability to recognise seriousness of Kevin’s condition
  • Appropriate interventions not taken
  • Selective and incomplete transmission of information.
  • Non receipting of vital information
  • Absence of integrated pathways
  • Link between behaviour and test results not made
  • Developing neurological problems ignored
  • ABSENCE OF DIRECT COMMUNICATION
  • WITH THE PATIENT
shortcomings contd
Shortcomings Contd…
  • Treatment at Registrar level
  • The team dynamic
  • The impact of a weekend admission
  • Patient asked to accommodate system?
  • System intended to accommodate patient?
  • Expectations of a Tertiary Training Hospital
the response of doctors
The Response of Doctors
  • Defensive
  • ‘Loyalty to colleagues’
  • Muddying the waters – dissembling
  • - e.g. Claims of inability to understand ‘layspeak’
  • Attempts to shift responsibility
  • Confidence in any hope of ascertaining truth shattered
  • Excuses offered were unsustainable to the point of being offensive
  • Expectation of professional and honourable conduct betrayed
legal route to finding answers
Legal Route to Finding Answers
  • System favours defendants
  • Disempowerment of plaintiff
  • Plaintiff takes huge personal risks
  • “David and Goliath” experience
  • Wearing-down process
  • Lack of compassion
a wish list do it right
A Wish List : Do it Right!
  • Observe existing guidelines, best practice and SOP’s. Be prepared to challenge each other in that regard
  • Following adverse outcomes undertake “root cause analysis” "system failure analysis"/"critical incident investigation”.
  • Communicate effectively within the medical community and with patients
  • Keep impeccable records
  • Listen to patients and families
  • Respect patients and families
  • ACKNOWLEDGE ERROR
  • AND ALLOW LEARNING TO OCCUR
a wish list continued
A Wish List Continued
  • Know your personal limitations
  • Replicate what is good and be always vigilant for opportunities to improve.
  • Learn and disseminate that learning
  • Practice dialogue and collaboration – meaningful engagement with patients and families
  • Create a coalition of healthcare professionals and patients
  • ACKNOWLEDGE ERROR
  • AND ALLOW LEARNING TO OCCUR
validating the way forward
Validating The Way Forward
  • Acknowledging the reality as experienced by patients - real people.
  • Patient-centred care is intended to be just that. Robust data collection needs to include for patient input.
  • Patients as part of the process.
  • Concretising the role of improved patient safety data systems in revealing root causes (the real issues that need to be addressed) and in driving quality assurance in relation to improved outcomes for patients.
  • The absolute need for improved patient safety data systems to result in measurable improved outcomes for patients.
slide20
THANK YOU
  • Margaret Murphy
  • June 2006
  • m33g33t@yahoo.co.uk