Memorandum by MRSA Action UK (PS 29)
1. The Charity MRSA Action UK's purpose
is to relieve the distress and suffering experienced by patients
who contract healthcare infections. By producing materials, to
serve as an aid, our aim is to provide an advocacy and support
service to families and their carers. We aim to raise the awareness
of the general public in all areas relating to healthcare infections.
We work alongside patient groups, regulators and government agencies
to bring improvements and safer standards in the healthcare system.
Patients, their families and representatives, healthcare workers
and other professionals contact us on a daily basis requesting
advice and seeking help.
2. We have responded on the role of human
error and used our experience from dealing with patients, regulators
and healthcare professionals, which demonstrate how leadership,
communication and working collaboratively can help to mitigate
3. We believe there needs to be much more
attention paid to training in clinical practices, such as aseptic
technique. Guidance and training on antibiotic prescribing and
looking across the whole patient journey feature in the submission.
We also believe that the under-reporting on death certificates
of pathogens needs addressing, Trusts should have policies based
on ONS guidelines on death certification that are subject to audit.
Surgical Site infections should also be published on a quarterly
basis with MRSA bacteraemias.
4. The real toll to healthcare infections
and on patient safety needs to be in the public domain, this we
feel will be an incentive to improve and save lives.
What the risks to patient safety are and to what
extent they are avoidable?
The Role of Human Error
5. In every walk if life, there is always
a chance of error. As Humans we possess an innate tendency to
be imprecise"to err is human." Human nature comprises
all mental, emotional, social, physical, and biological characteristics
that can define human tendencies, capabilities, and limitations.
For instance, humans tend to perform very poorly under high stress
and time pressure. Due to human variability, the most reliable
any human being can possibly be is on the order of 99.99+ percent.
Therefore error is always a factor to be reckoned with in any
6. Due to inherent fallibility, human beings
are very vulnerable to external working conditions that may test
their limitations, such as lighting, heat, equipment, coworkers,
and procedures. Our vulnerability to such conditions increases
our chances to err. This is especially true when people work within
complex environments (such as hospitals or any medical facility)
that contain hidden flaws and weaknesseslatent conditions
that can either provoke error or weaken defenses against the consequences
7. The role of human error happens at the
point where medical staff touches hospital equipmentthat
is the place where either the physical or paper environment can
be changed. The physical environment comprises of systems, buildings,
wards, theatres, and other such components that function to treat
or care for patients. The paper environment however consists of
the design bases and other documentation used to maintain control
of the physical environment's configuration. Inaccuracies in the
paper environment, such as incorrect design calculations and inaccurate
procedures, can lie dormant and lead to undesirable outcomes in
the physical environment or even personal injury when events do
not function as anticipated.
8. Not all decision-making, problem-solving,
and manual actions are the result of conscious, intentional thoughts.
A significant portion of mental activity occurs unconsciously.
These common traps of human nature provide more reasons to be
The Common Traps for Human Error
9. Due to the fact that consequential errors
rarely occur, people tend to overestimate their ability to maintain
control while they work. There is in a sense a general lack of
appreciation of the limits of human capabilities. Whenever/wherever
the limits of human capabilities are challenged, the likelihood
of error increases. The following characteristics of the role
of human error, among others, are commonly encountered whenever
performing tasks in a complex work environment.
10. StressEffective strategies for
reducing the effects of stress and improving performance include
good health, skills training, procedure adherence, and teamwork.
11. Mental Strain AvoidanceHumans
are naturally reluctant to engage in concentrated thinking, as
it requires high levels of attention for extended periods. Thinking
is a slow, laborious process that requires concerted effort. Consequently,
people tend to look for familiar patterns and apply well-tried
solutions to a problem. They are tempted to settle for satisfactory
rather than the best solutions. Mental biases, or shortcuts, used
to reduce mental effort include the following:
assumptionsa condition taken
for granted or accepted as true without verification of the facts
habitan unconscious pattern
of behavior acquired through frequent repetition
confirmation biasthe reluctance
to abandon a current solutionto change one's mindin
light of conflicting information due to the investment of time
and effort in the current solution; this bias orients the mind
to "see" evidence that supports the original supposition
and to ignore or rationalize away conflicting data.
similarity biasthe tendency
to recall solutions from situations that appear similar to those
that have proved useful from past experience
frequency biasa gamble that
a frequently used solution will work; giving greater weight to
information that occurs more frequently or is more recent
availability biasthe tendency
to settle on solutions or courses of action that readily come
to mind and appear satisfactory; more weight is placed on information
that is available (even though it could be wrong). This is related
to a tendency to assign a cause-effect relationship between two
events because they occur almost at the same time.
Systems FailuresA Strategic Approach
12. For there to be a successful strategic
approach we need to see that there is consistency throughout the
whole of an organisation. This approach has to be coordinated
in that there are some 400 Trusts within the National Health Service
and at the present moment this is far too fragmented for any successful
strategic approach to have any reasonable chance of success. Patient
care and safety have to be of the highest quality, and the safety
of the patient has to take priority over all other considerations
such as targets set by central Government.
13. Strategically, there should be four
cornerstone programs, those being, evaluation, assistance, training,
and operating experience. These would help reduce the frequency
and severity of adverse events. The Anatomy of an Event model,
which describes the origin and development of an event triggered
by human error, illustrates two strategic focal points to reduce
the frequency and severity of human performance events: initiating
actions at the point of action and latent organisational weaknesses.
Industrial sources at various highly successful companies support
the logic of this approach. Therefore, a coherent human performance
management strategy should address two primary challenges:
Reduce the frequency of events by
anticipating, preventing, and catching active errors at the event
Minimize the severity of events by
identifying and eliminating latent weaknesses that hinder the
effectiveness of defenses against active errors and their consequences.
14. Eliminating the role of human error
is more likely if front-line staff, support staff, and managers
embrace the following underlying truths, or principles, that provided.
Integrating these principles into management and leadership practices,
staff practices, and the organisation's processes and values will
help guide the development of a philosophy and strategy for eliminating
human error, as well as providing guidance for the planning and
conduct of work in the hospital.
People are fallible, and even the
best people make mistakes.
Error-likely situations are predictable,
manageable, and preventable.
Individual behavior is influenced
by organisational processes and values.
People achieve high levels of performance
largely because of the encouragement and reinforcement received
from leaders, peers, and subordinates
Events can be avoided through an
understanding of the reasons mistakes occur and application of
the lessons learned from past events (or errors).
How far the Boards of NHS bodies have established
a safety culture?
15. In terms of healthcare infections there
are significant regional disparities in achieving reductions in
MRSA and Clostridium difficile. The perception from attending
events and visiting Trusts it would appear that not all have a
commitment from Board to Ward. Some staff have actually made the
comment that it is still difficult to get full commitment from
16. There is not a joined up approach to
looking at the whole patient journey when it comes to healthcare
infections. There needs to be a recognition that a resistant pathogen
will go from one healthcare setting to another after a patient
is discharged, and of course back to the Acute setting if the
patient needs more treatment. There needs to be more of a focus
on screening high risk patients, for example those who may be
receiving care from Oncology post-discharge.
17. Patients being discharged to care homes
may be at risk from pressure sores, therefore working with tissue
viability nurses to help avoid infection is important.
18. Staff in some care homes when asking
us for advice state they are worried about looking after patients
who have MRSA. From the information they ask it is clear they
have had little or no training on infection prevention and control.
Systems for incident reporting, risk management
and safety improvement
19. We would like to see more collaboration
between healthcare regulators and the National Patient Safety
Agency. As part of our role on the Healthcare Commission Expert
Reference Group for assessing arrangements for checking Trusts
arrangements for the implementation of the Hygiene Code, there
appeared to be a lack of clarity on how the two organisations
can complement each others work.
20. There does appear to be some joint working
emanating from the Healthcare Commission inspections of the Acute
Trusts, they may for example bring to the attention of the NPSA
findings relating to benchtop sterilisers, but have not been proactive
in following this up to see what the NPSA will do with the informationthe
NPSA could for example issue medical alerts.
21. The information reported by staff and
patients to the NPSA National Reporting and Learning System (NRLS)
is confidential, however if there were extreme cause for concern
we would like to see some form of early warning system giving
to regulatory bodies such as the new Care Quality Commission.
22. For example the reporting system was
still in its infancy when the Healthcare Commission investigated
two outbreaks of Clostridium difficile in Stoke Mandeville Hospital
in 2004-05 with fewer than 50 Trusts using the reporting system,
so it may be difficult to draw any conclusions from reports of
incidents at that time, but may merit further investigation.
23. However in the winter of 2005-06 Maidstone
& Tunbridge Wells NHS Trust, and prior to this in 2004, there
were significant and now well known outbreaks, and this NHS Trust
was not unique in having high incidence of Clostridium difficile.
Similarly a review of arrangements was carried out at University
Hospitals of Leicester NHS Trust regarding the high number of
cases of Clostridium difficile in 2005 and 2006.
24. In the April to March 2006 report from
the NPSA NRLS there were 6,129 incidents relating to infection
control in Acute / general hospitals in England. If there were
a correlation with high numbers of incidents would the NPSA flag
this up to the regulator, these incidents if controlled are largely
avoidable and such an early warning system has the potential to
25. Patients can now also report incidents.
Whilst we recognise the NRLS is a tool for learning and improving,
patients and staff may feel that lessons will not be learned if
incidents are not reviewed. We welcome this reporting system but
we feel that investigation and route cause analysis are essential
in helping to understand how lessons can be learned.
26. We actively encourage the use of this
system, indeed there is a link to reporting system on MRSA Action
27. The Joint Commission in the USA offer
a Patient Safety reporting mechanism. It may be done anonymously,
but contact details are needed so that complaints can be investigated
and a response supplied. It may be necessary to share the complaint
with the organisation in the course of a complaint investigation.
The Joint Commission policy forbids accredited organisations from
taking retaliatory actions against employees for having reported
quality of care concerns to The Joint Commission. We believe the
NPSA should operate in the same way.
28. We note that the NRLS is now more widely
used, the numbers of reported incidents relating to infection
control total 12,271 for England for 2007-08, which is 2% of all
reported incidents. We would hope to see some use of this information
with the new regulator to flag up significant concerns and make
recommendations for improvement.
29. The latest Patients Association report
following a survey of patients, describes the NHS complaints system
as "cumbersome, variable and takes too long." Of the
patients polled, 69% said they had wanted to complain about the
healthcare they had received in the last five years. For those
who complained, 29% described the process as "totally pointless"
and only 2% said the experience had been "very useful".Source
Press Association 21st September.
30. We also have similar experiences in
opinion from our own work with patients who have had cause to
use the NHS Complaints procedure.
Involving patients and learning from complaints:
31. There are common themes in the requests
for information and assistance with complaints which we receive
from patients and their carers:
Insufficient information for the
patient/carer to play an active role in mitigating the risk of
contracting an infection
When a patient contracts an infection,
insufficient information offered on the implications and how to
treat and control the infection
Information not passed on through
the patient journey from the Acute setting to the Primary Care
Inadequate response to comments or
complaints missing opportunities to heed lessons learned
Failure to adhere to policies and
procedures designed to mitigate risks
Sloppy clinical techniques when inserting
IV lines, cannulae and catheters
Education for health professionals
32. We believe there needs to be ongoing
education for health professionals in clinical practice. Patients
regularly report that attention is not paid to pristine hygiene
practices when dealing with IV lines, drips, cannulae and catheters.
This occurs in the Acute and Primary Care setting. We are beginning
to see numbers of patients who report incidents at GP surgeries
in relation to "sloppy" hand hygiene and aseptic technique.
The public are becoming more aware of infection prevention, however
few feel they can confidently ask a health professional to wash
their hands or ask that clinical procedures are carried out effectively.
33. The Royal Colleges have a role to play
not only in accrediting competency but we believe in helping to
carry out audits of competency within the healthcare setting.
Observation of clinical techniques should be carried out on a
regular basis, this can be done by peers in the healthcare setting,
however regular trained external observers will always see something
that a peer may miss. The Improvement Teams who are working on
the Cleaner Hospitals programme have identified the need for external
34. Training in antibiotic prescribing would
be beneficial, there is still a tendency to prescribe broad-spectrum
antibiotics before making a diagnosis of a patient's condition,
elderly patients are at particular risk from Clostridium difficile
when using broad-spectrum antibiotics.
What should be measured and assessed; and what
data should be published?
35. We know that the true picture regarding
MRSA is not published. Trusts are saying they have no MRSA when
in fact, they have recorded no MRSA bacteraemias. The Health Protection
Agency collect data on surgical site infections and we believe
this data set should also be published as part of the quarterly
reporting. This helps patients make informed choices about where
they are most likely to go for treatment.
36. We believe that death certification
needs to include the pathogens MRSA or Clostridium difficile where
these are the cause or contributory factor to a patient's death.
Patients have experienced the non-recording of this as a cause,
and they know from reviewing case notes that these pathogens were
a contributory factor. Evidence from the National Confidential
Study following MRSA Infection published by the Health Protection
Agency in 2007, demonstrated that more than half the case notes
reviewed should have had either sepsis or MRSA listed as a contributory
factor, and that all of the clinicians interviewed had said they
were unaware of the Trusts policy on the recording of MRSA.
Derek Butler, Chair
MRSA Action UK