How does CORESS help Patient Safety?
CORESS has adapted, for use by surgical teams, a system which has been operating successfully in Aviation and Marine industries since the mid 1970s. This is ‘The Confidential Human Factors Incident Reporting Programme (CHIRP)’. In brief this elicits reports of precursor events which otherwise go undetected and ‘under the radar’. The key feature is the separation of reporting, analysis and feedback from any connection to the employer or regulator – and most importantly, to preserve absolute confidentiality.
The Importance of Confidentiality
It has been shown and long accepted in Aviation and other high stakes industries such Marine and Rail that, even if mistakes have been made and although it may be the system which is mainly at fault, fear of reprisal often deters staff from reporting incidents to in-house systems. This is confirmed by experience which demonstrates that when reporting/feedback systems are clearly separate from employers, the reporting rate increases. To attract confidential reports of near-miss and low harm events, CHIRP successfully developed the concept of a third party separate from any outside agencies and which acts as an ‘Honest Broker’.
Reports received by CORESS are analysed, and the learning published regularly to a wide audience as a series of illustrative feedback cases or vignettes. Where system design or equipment problems are implicated, CORESS relays the dis-identified information to the appropriate regulator.
It is generally accepted that a range of issues are usually at play in any adverse clinical event, including human factors. Based on his 5-years of work with CORESS, Professor Kapur has developed a schema, which captures five key factors, helpful to those working in the field of clinical negligence. These are as follows:
Staff, the individuals, the interactions between them e.g., fatigue, stress, and uncertainty of role etc.
- Environment, both physical and organisational, e.g., noise and bed pressure, respectively.
- Information, e.g., lack of availability on time, errors, communication failures etc.
- Task, which may be its complexity or timing elements within it.
- Patient, e.g., specific characteristics, fragility, co-morbidities etc.