Objectives

2. Objectives By the end of this session you will be able to: • explain the term ‘error’ • explain why errors are made • describe individual strategies to reduce the frequency of errors

3. Patient Safety and the Australian Curriculum Framework for Junior Doctors

4. Adverse events in health • Contribute to about 18,000 deaths per year in Australia (approximately 10 times the road toll) • Occur in up to 16% of all hospital admissions Quality in Australian Healthcare Study (Wilson et al. MJA 1995) Ice Breaker Click to view video

6. Have you made anysilly mistakes recently? What happened?....... What were the consequences?.....

7. What is an “error”? “Doing the wrong thing when meaning to do the right thing” (Runciman) • A more formal definition is: (Reason) • “planned sequences of mental or physical activities that fail to achieve their intended outcomes, when these failures cannot be attributed to the intervention of some chance agency”

8. Error and outcome • Error and outcome are not inextricably linked • Harm can befall a patient in the form of a complication of care without an error having occurred1 • Many errors occur that have no consequence for the patient either due to a timely intervention (eg clinical pharmacist intercepting wrong dose) or due to chance • (QAHCS – 75% of incidents had an element of ‘human error’)

9. Basic principles about error • We all make errors all the time • The same error (even minor ones) can have different consequences • Errors are not bad or morally wrong – BUT Healthcare workers expect perfection of themselves (and colleagues) AND We often ascribe blame to individual without looking at wider circumstances Adapted from Queensland Health Human Error and Patient Safety Training (HEAPS)

10. In hospitals the effects of small errors can be large!

11. Outcome Definitions • Clinical incident • Near miss (or ‘no-harm incidents’) • Adverse event (or ‘harm incidents’) • Harm • Sentinel event • Clinical incidents = Near misses (90%) + Adverse events (10%)

12. Types of errors Reason

13. Types of errors • Slips - I put salt in my tea not sugar… • Lapses - I was interrupted and forgot to take the document out of the copier… • Usually repetitive actions • Mistakes - I thought the problem was hypovolaemia but it was cardiogenic shock… • Wrong plan or action

14. Courtesy P. Croskerry Courtesy P. Croskerry

15. Courtesy P. Croskerry

16. Courtesy P. Croskerry Courtesy P. Croskerry

21. Why do we misinterpret things sometimes? Because the human brain is so…. • Good at finding shortcuts (fast) • Good at filtering information • Good at making sense of things • Usually this is a good thing, sometimes it fools us • Error is the “downside to having a brain”!

22. The environment can “set us up” to make errors • look-alike and sound-alike pharmaceuticals • equipment design • e.g. defibrillators • user interfaces • e.g. infusion pumps

23. Situations leading to error:The “Three Bucket” model Distraction Inadequate handover Production pressure Equipment failure Poor knowledge Fatigue Little experience Feeling ill Variation from “normal” Omission errors Unfamiliar equipment Reason 2004

24. VIDEO • Watch this video of a “typical day” in the emergency department • How did the mistakes come about? • Were they inevitable or avoidable? Faultlines part 1 Click to view video. Do not interrupt video once started. Let video run through its entirety.

26. VIDEO • What circumstances have you noticed so far that may contribute to an error? • What strategies is the junior doctor using to minimise these factors? Faultlines part 2 Click to view video. Do not interrupt video once started. Let video run through its entirety.

28. What were the contributing factors in this case? Variation from “normal” Omission errors Unfamiliar equipment Poor knowledge Fatigue Little experience Feeling ill Distraction Inadequate handover Production pressure Equipment failure Reason 2004

29. Performance-shaping factors • I Illness • M Medication • prescription, alcohol & others • S Stress • A Alcohol • F Fatigue • E Eating Am I safe to work today?

30. Stress and Performance Area of “Optimum” Stress Performance Level High Stress Anxiety, Panic Low Stress Boredom Stress Level The Relationship Between Stress and Performance

31. Stress and Performance

32. Don’t forget …. If you’re • H ungry • A ngry • L ate or • T ired ….. H A L T

33. Personal error reduction strategies • Know yourself • eat well, sleep well, • look after yourself … • Know your environment • Know your task • Preparation & planning • “What if …?” • Build ‘checks’ into your routine • Speak up if you don’t know!

34. Systems problems • May be inadequate staffing, too busy etc. • Design of equipment makes it difficult to do the right thing • Difficulties working as a team • No or patchy orientation • Often no clear accountability • No ‘standard operating procedures’ • Culture which allows unacceptable behaviours

35. Communication and Teamwork • Be precise with your communication • Use clinical terms not social speak • Practice effective handovers • Encourage ‘read-back’ of important information • eg. Confirming instructions or drug doses if given over the telephone • Remember to have structured briefings (‘Time outs’) before procedures • Have a structure and plan what you need to say…

36. Education package available from PMCV and Southern Health

37. Mental preparedness • Assume that errors can and will occur • Identify those circumstances most likely to lead to error • Have contingencies in place to cope with problems, interruptions and distractions – discuss them aloud with your team • Mentally rehearse complex procedures Getting the balance right

38. Technology • New technology doesn’t solve the problems • New technology makes new problems or can even make old problems even worse!

39. New technology makes new errors… Errors in counting drops per minute Risk of unnoticed occlusion Mis-programming (eg. 10-fold or decimal point errors) Risks of malfunction, battery failure, ignoring alarms etc. OR OR

40. Summary • Making errors is an inevitable part of the human condition - it’s how we’re built! • Be aware of yourself, the context and the task – ask: • “what are the risks?” • “what are the ways to minimise the risk?” • Communicate effectively and use your team – they are your eyes and ears